Endoscopic beating-heart stabilizer and vessel occlusion fastener

ABSTRACT

Devices, systems and methods related to endoscopic surgery, particularly related to robotic surgical operations, provide a tissue stabilizer for endoscopically stabilizing a target tissue within a patent&#39;s body. For stabilizing a beating heart during a closed-chest coronary artery bypass grafting procedure, a stabilizer is inserted through an endoscopic cannula and provides sufficient surface area to contact the heart and effectively stabilize the target tissue area. The stabilizer can straddle a blood vessel, such as a coronary artery, which is targeted for an anastomosis. Vessel occlusion fasteners may occlude the target blood vessel prior to the anastomosis procedure.

CROSS-REFERENCES TO RELATED APPLICATIONS

[0001] The present application also claims the benefit of priority fromthe following U.S. patent applications:

[0002] Ser. No. 60/290,556, filed May 10, 2001, for “EndoscopicBeating-Heart Stabilizer Including Adjustable Irrigator and VesselOcclusion Fastener” (Attorney Docket No. 017516-002570);

[0003] Ser. No. 60/285,641, filed Apr. 19, 2001, for “EndoscopicBeating-Heart Stabilizer” (Attorney Docket No. 017516-002560);

[0004] Ser. No. 60/253,484, filed Nov. 28, 2000, for “EndoscopicBeating-Heart Stabilizer” (Attorney Docket No. 017516-002550).

[0005] And the present application is a continuation-in-part and claimsthe benefit of priority from Ser. No. 09/436,524, filed Nov. 9, 1999,for “Stabilizer for Robotic Beating-Heart Surgery” (Attorney Docket No.017516-002530), now issued as U.S. Pat. No. ______;

[0006] The full disclosures of each of the above referenced patentapplications are incorporated herein by reference.

STATEMENT AS TO RIGHTS TO INVENTIONS MADE UNDER FEDERALLY SPONSOREDRESEARCH OR DEVELOPMENT

[0007] Not Applicable

REFERENCE TO A “SEQUENCE LISTING,” A TABLE, OR A COMPUTER PROGRAMLISTING APPENDIX SUBMITTED ON A COMPACT DISK

[0008] Not Applicable

BACKGROUND OF THE INVENTION

[0009] This invention generally relates to surgical tools, methods, andsystems for stabilizing, retracting, and/or inhibiting physiologicalmovement of tissues. In a particular embodiment, the invention providesan endoscopic and optionally robotic surgical stabilizer for use duringendoscopic and robotic surgical treatments on a beating heart.

[0010] Coronary artery disease remains a leading cause of morbidity andmortality, and particularly in industrialized societies. A number ofapproaches have been developed for treating coronary artery disease.While lifestyle changes, endovascular approaches (such as balloonangioplasty, atherectomy, and the like) and/or pharmaceutical treatmentsare often effective, in many cases it is necessary to resort to surgicalprocedures such as coronary artery bypass grafting to effectively treatcoronary artery disease.

[0011] Coronary artery bypass graft (CABG) procedures are commonlyperformed using open-heart techniques. Conventional CABG procedures aredescribed in U.S. Pat. No. 5,452,733 which is fully incorporated hereinby reference. These open procedures generally involve dividing thepatient's sternum and spreading the chest to provide access to theheart. The patient is placed on a cardiopulmonary bypass (CPB) machine,which oxygenates the patient's blood and pumps it through the patient'scirculatory system during the surgical procedure. After the patient ison CPB, drugs (cardioplegia) are administered to temporarily stop thepatient's heart to allow the grafting procedure to be performed.Conventional CABG procedures often involve bypassing a narrowed coronaryartery by one of two methods. First, existing arteries can be dissectedat one end from their natural attachments and transected to a locationdownstream of the narrowed portion of the coronary artery. Theconnection site of the graft and the artery is termed an anastomosis.Thus, arterial blood flowing through the existing artery bypasses thenarrowing and outputs into the coronary artery which was previouslyrestricted of flow. Second, artificial arterial shunts may be preparedby attaching a natural or synthetic blood vessel, typically a lengthobtained from a leg vein, at one end to the proximal ascending aorta andat the other end to the target location on a coronary artery downstreamof the narrowing. The use of transected arteries is generally preferablesince they tend to remain patent for long periods and require only oneanastomosis.

[0012] When existing arteries are used to bypass a narrowing, the leftor right internal mammary artery is often utilized. The left internalmammary artery is suitable as an arterial source for target locations onthe left anterior descending coronary artery, the diagonal coronaryartery, the circumflex artery/obtuse marginal artery, and the ramusintermedius coronary artery. The right internal mammary artery isavailable for connection to all of the same target locations, as well asthe right coronary artery and the posterior descending artery. It willalso be possible to use the gastroepiploic artery in the abdomen. Whenexisting arteries are not available, veins or arteries may be harvestedfrom other locations in a patient's body or synthetic grafts may beused. The grafts thus located will be attached at one end to theproximal ascending aorta (to provide the arterial blood supply) and atthe other end to the target location on the coronary artery.

[0013] One drawback of conventional CABG procedures is the use of CPB.The use of CPB has been associated with an increased rate of stroke andneurological deficit. Consequently, techniques and devices have beenproposed for performing open-heart surgery on a heart while the heart isbeating. This eliminates the need for CPB. However, the grafting andanastomosis procedure is often more challenging on a beating heart thanon a heart that has been stopped by cardioplegia. To reduce movement ofthe heart in the grafting area, a tool called a stabilizer is often usedto engage the heart and stabilize the area of interest.

[0014] While elimination of CPB may improve the outcomes of manypatients, the use of open-heart surgery to perform CABG is still highlytraumatic to the patient. Thus, minimally invasive medical techniquesfor performing cardiac surgeries have recently been proposed. Here, thechest cavity is not opened; rather, the heart is accessed through portsor small incisions in the chest through which instruments are inserted.Arteries may be manipulated within the body to provide arterial bloodsupply to restricted coronary arteries. For example, access to thegastroepiploic artery can be obtained laparoscopically with the arterybeing brought into the thorax from the abdominal cavity via a windowthrough the diaphragm. Likewise, grafts may be passed into the thoraxthrough either an access trocar sheath or through the aorta (by punchinga hole therethrough). These minimally invasive techniques are generallyaimed at reducing the amount of extraneous tissue which is damagedduring diagnostic or surgical procedures. This can effectively reducethe patient's recovery time, discomfort, and other deleterious sideeffects of cardiac surgery.

[0015] Unfortunately, both the proposed techniques for minimallyinvasive cardiac surgery and the proposed techniques for beating-heartcardiac surgery significantly increase the difficulty of these alreadycomplex surgical procedures. Formation of the anastomosis (theconnection between the arterial source and the occluded artery) is quitechallenging in a standard coronary artery bypass grafting procedure whenthe heart tissues are immobile and exposed for direct manipulation. Evenskilled surgeons may find it awkward and/or time consuming to insteadperform such procedure in a minimally invasive manner or while the heartis beating.

[0016] In robotically assisted surgery, the surgeon typically operatesone or more master controllers to remotely control the motion ofsurgical instruments at the surgical site. The controller may beseparated from the patient by a significant distance (for example,across the operating room, in a different room, or in a completelydifferent building than the patient). Alternatively, the surgeon's workstation with the controllers may be positioned quite near the patient inthe operating room. Regardless, the controller will typically includeone or more hand input devices, such as a joystick, exo-skeletal gloves,or the like. The hand input devices of the surgeon's workstation aregenerally coupled to the surgical instrument by a servomechanism. Morespecifically, servomotors move a manipulator, or “slave” supporting thesurgical instrument based on the surgeon's manipulation of the handinput devices.

[0017] During a robotic surgical operation, a surgeon using a roboticsurgical system may employ, via the manipulator, a variety of surgicalinstruments, such as tissue graspers, needle drivers, electrosurgicalcautery probes, and the like. Each of these structures perform functionsfor the surgeon, for example, holding or driving a needle, grasping ablood vessel, dissecting, cauterizing, and/or coagulating tissue, andthe like. The surgeon and/or an assistant will mount robotic surgicalinstruments having suitable end effectors to the manipulator, and willoften pass the end effectors through cannula sleeves to an internalsurgical site, so as to treat the targeted tissues while minimizinginjury to the adjacent tissue structures.

[0018] In light of the above it would be desirable to provide medicaldevices, systems, and methods which would facilitate roboticallyperformed endoscopic surgery on tissues undergoing physiologicalmovement. It would be particularly desirable if these devices, systemsand methods facilitated coronary artery bypass grafting on a beatingheart under closed-chest conditions. It would further be beneficial toprovide means for occluding the vessel or coronary artery during theprocedure which are independent of the instrumentation so that thevessel may remain occluded while the instrumentation is repositioned. Atleast some of these objectives will be met by the present invention.

SUMMARY OF THE INVENTION

[0019] The present invention provides devices, systems and methodsrelated to endoscopic surgery, particularly related to robotic surgicaloperations. In particular, the present invention provides a tissuestabilizer for endoscopically stabilizing a target tissue within apatent's body. A primary example would be for stabilizing a beatingheart during a closed-chest coronary artery bypass grafting procedure.The stabilizer of the present invention is designed to be insertedthrough an endoscopic cannula yet provide sufficient surface area tocontact the heart and effectively stabilize the target tissue area. Inaddition, the stabilizer is designed to straddle a blood vessel, such asa coronary artery, which is targeted for the bypass procedure.Typically, an anastomosis is created at the targeted site straddled bythe stabilizer. Further, the present invention includes vessel occlusionfasteners to occlude the target blood vessel prior to the anastomosisprocedure. This provides a bloodless field when performing theanastomosis procedure.

[0020] The stabilizer will typically be coupled to and supported by adrive system or a mounting system to position the stabilizer fromoutside the patient. The stabilizer is preferably inserted through acannula or trocar sleeve emplaced in an incision in the patient's body.In some embodiments of the invention, the stabilizer and mounting systemmay be coupled to the actuators of a servomechanism of a roboticsurgical system.

[0021] Alternatively, in other embodiments of the invention, thestabilizer may be endoscopic and non-robotic, e.g., may coupled to apositionable mounting apparatus fixed to the operating table or anadjacent base. When the stabilizer is non-robotic, the stabilizer may bemanually positioned by an operator outside of the body and/or thestabilizer may be positioned by robotic surgical instruments from withinthe body. The robotic surgical instruments include a plurality ofmanipulators with actuators for moving surgical end effectors inresponse to inputs by a system operator into an input device. The endeffectors of the surgical instruments may be used to grasp portions ofthe stabilizer and adjust or reposition them.

[0022] In a first aspect of the present invention, the stabilizercomprises an elongate shaft sized to allow insertion through anendoscopic cannula and a manipulable foot connected with the shaft. Thefoot is used to engage a target tissue, such as a portion of a beatingheart, for stabilization. The stabilizer can inhibit (i.e.,substantially reduce) physiological motion of the stabilized regionwithout having to stop the heart. While the stabilized region will notnecessarily be absolutely still, motion of the target tissues can beinhibited sufficiently to treat the target tissues, particularly withrobotic surgical tools which move in response to inputs of a roboticsystem operator.

[0023] In some embodiments, the manipulable foot comprises a first toeportion rotateably joined with a second toe portion. The first toeportion and second toe portion are rotateable to a first arrangementwherein the foot is insertable through an endoscopic cannula. Suchrotation will be described in detail below. Mounted on each toe portionis a stabilizing surface or tissue engaging member. Typically, suctiontubes are inserted through suction lumens in the shaft and are connectedwith each tissue engaging member. Each tissue engaging member comprisesas least one suction port through which the suction is provided.Typically, the suction ports are disposed on the underside of the tissueengaging members so that suction is applied when the tissue engagingmember is applied to the target tissue. Such suction secures the memberto the tissue surface and stabilizes the tissue.

[0024] In some embodiments, the toe portions are joined in a toeassembly which allows the toe portions and associated tissue engagingmembers to rotate, thus reducing the dimensions of the foot to allow thefoot to be inserted through a cannula. In some instances, the toeassembly comprises a top ball shell, a first toe portion, a torsionspring, a second toe portion, a bottom ball shell and a rivet which isinsertable through these components of the assembly to hold them inplace. In these embodiments, each toe portion includes a ring mount. Thecomponents of the assembly are assembled so that the ring mount of thefirst toe portion fits within the top ball shell, the torsion springfits within a ring notch in each ring mount of the first and second toeportions, and the ring mount of the second toe portion fits within thebottom ball shell. Together, the assembly provides a spring-loaded,collapsible pair of toe portions which are joined at one end to form aspherical split ball shell.

[0025] In a second aspect of the present invention, the stabilizercomprises an adjustable ankle disposed between the foot and the shaft.By adjusting the ankle, the foot is moveable in six degrees of freedomrelative to the shaft. In some embodiments, the ankle includes anadjustable neck. In some cases, the adjustable neck comprises a seriesof interlocking elements and intermediate socket rings. Typically, theelements are comprised of balls or ball portions. Each ball isindependently rotateable against an adjacent ring to allow the neck tobe adjusted. In further embodiments, the ankle also includes an outerhousing. A spherical split ball shell, as described above, is mountablewithin the housing so that the spherical split ball shell is rotateablewithin the housing. This allows the position of the foot to be adjustedin relation to the shaft.

[0026] In a third aspect of the present invention, the stabilizercomprises a tension cable passing through the shaft wherein applyingtension to the cable locks the ankle in position. Such locking may beachieved with the use of cable anchor such as a locking ball which isattached to the distal end of the tension cable and is disposed withinan inner housing. Both the locking ball and inner housing are disposedwithin the outer housing. Applying tension to the cable moves thelocking ball toward the shaft. This in turn locks the ankle and the footin place. When the ankle includes an adjustable neck comprising a seriesof interlocking balls and intermediate rings, the neck may be fixed byapplying tension to the cable so that the cable wedges the balls andsocket rings together and holds them in place by friction. Thus, theankle is locked in position. Movement of the locking ball toward theshaft also moves the outer housing toward the shaft. When a sphericalsplit ball shell is disposed within the outer housing, as describedabove, movement of the outer housing holds the spherical split ballshell in place and restricts its rotation. Thus, the foot is locked inplace.

[0027] In a fourth aspect of the present invention, the stabilizercomprises at least one suction tube connectable with at least onesuction port on the stabilizer foot. Generally, the suction tubes areinsertable through suction lumens in the shaft so as to extend distallythrough the shaft face. In some embodiments, the suction tubes have anelongated shape with a stopper connector portion at its proximal end anda flexible portion at its distal end. The suction tube includes asuction tip disposed at the distal end having one or more suction holes.The suction tip is insertable into a suction tube receptacle in thetissue engaging member so that the suction holes communicate with thesuction ports. Suction is provided through the suction ports so thatsuction holds the stabilizer in firm contact with the target tissue.

[0028] In a fifth aspect of the present invention, the stabilizercomprises an irrigator. In most embodiments, the irrigator is insertablethrough an irrigation lumen in the shaft so that it protrudes outwardlyfrom the shaft face. Fluids may be delivered to the target tissuethrough the irrigator as needed. The fluids may include liquids (e.g.,saline solution, and the like) or gases (e.g., insulation gas, carbondioxide, and the like). The fluids may be used for a number of surgicalpurposes, such as to remove blood from anastomotic site (e.g., by dripirrigating, washing or blowing) and the like. The fluids may also beused to remove blood or other substances from surgical devices, such ascleaning an endoscope objective in vivo, and the like. In someembodiments, the irrigator comprises an elongate conduit and a flexiblyadjustable dispenser. The dispenser terminates in a nozzle or spoutportion. The dispenser may be adjusted so that the spout portion isdirected at the target tissue so that fluid is delivered at the desiredlocation. Alternatively, a vacuum source may be applied to the irrigatormechanism to remove fluids from the body, the spout portion being placedat the location of collected fluids to act as an intake.

[0029] In a sixth aspect of the present invention, the stabilizercomprises a handle. As previously mentioned, once the stabilizer hasbeen positioned against the target tissue, the ankle and toe portionsmay be locked in place to prevent movement of the toes and to maintainproper orientation of the stabilizer. Such locking may be achieved byapplying tension to a tension cable. Such tension is applied to thecable with the use of the handle on the stabilizer. In some embodiments,the handle is pivoted to a body at a pivot pin and has an inboardportion which is attached to the cable. When the handle is rotatedownward, tension applied from the pivot pin to the inboard portioncauses the cable to be stressed and retracted upward. Ratchet pawls thenlock the handle in place preventing the handle from pivoting upwards.The cable is released by pressing a release button located on the handleso as to disengage the pawls.

[0030] In an additional aspect of the present invention, vesselocclusion devices are provided to isolate a blood vessel from bloodflow. To isolate a blood vessel, such as a coronary artery, the vesselis cinched upstream and downstream of the desired location foranastomosis. Thus, when the anastomosis is made, blood will not flow outinto the workspace. The vessel occlusion devices of the presentinvention each include a flexible member attached to a clip. Eachflexible member is passed under and around the vessel using instrumentsinserted within the chest cavity. Each flexible member is then tightenedand held by a fastening clip. In some embodiments, the fastening clipcomprises a generally elongate plate-like body which has at least one,typically two, holes or bores which intersects radial slots. One end ofthe flexible member is held in one radial slot, for example, by alocking pin. The free end of the flexible member then wraps around thevessel and is inserted through the second bore to form a loop. Aftertightening the flexible member to create desired constriction of thevessel, the flexible member is pulled into the adjacent radial slot,holding the flexible member in place.

[0031] The flexible members may be attachable with portions of thestabilizer. In particular, the flexible member can be attached to ananchor or cleat on the first and section toe portions so that movementof the first toe portion away from the second toe portion tensions theflexible member. Alternatively, the toe portions can be positionedagainst the target tissue and the free ends of the flexible memberattached to the positioned toe portions to hold the flexible member inplace. Thus, the vessel will remain cinched until the flexible membersare removed from the toe portions. However, in preferred embodiments, asdescribed above, the flexible members are held in place by the vesselocclusion devices themselves. In this way, the stabilizer may beadjusted and repositioned without affecting the position of the flexiblemembers.

[0032] In a method aspect, the invention provides a method forstabilizing a target tissue within a patient's body. In one embodiment,the method includes inserting a tissue stabilizer of the presentinvention through an endoscopic cannula and positioning the manipulablefoot of the stabilizer against the target tissue to stabilize thetissue. When the stabilizer includes toe portions having suction ports,such methods include applying suction to the target tissue through thesuction port to stabilize the tissue. When the stabilizer includes anyof the above described features, methods of the present inventioninclude positioning, manipulation, adjustment and/or use of any of thesefeatures.

[0033] In another method aspect, the invention comprises positioning oneor more vessel occlusion devices to restrict blood flow through a bloodvessel. Other objects and advantages of the present invention willbecome apparent from the detailed description to follow, together withthe accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

[0034]FIG. 1 is a schematic plane view of a portion of an operating roomshowing a typical robotic surgical system performing a minimallyinvasive robotic surgical procedure.

[0035]FIG. 2 illustrates access through a body wall with roboticallyoperated surgical instruments and the stabilizer of the presentinvention.

[0036]FIG. 3 illustrates an embodiment of the foot of the stabilizer ofthe present invention and vessel occlusion fasteners positioned toocclude a vessel of interest.

[0037] FIGS. 4A-4E illustrate an embodiment of a fastening clip of thepresent invention.

[0038]FIG. 5 is a full view illustration of an exemplary embodiment ofthe stabilizer of the present invention.

[0039] FIGS. 6A-6B illustrate an embodiment of the positioning andclamping system for the stabilizer when used in minimally invasivesurgery.

[0040] FIGS. 7A-7B illustrate an embodiment of the toe portions of thefoot of the stabilizer.

[0041]FIG. 8 illustrates the assembly of the toe portions.

[0042]FIG. 9A shows the assembly of the toe portions joined with theankle.

[0043] FIGS. 9B-9K illustrate an embodiment of how the toe portions1042, 1046 may collapse from a deployed or expanded position to a furledor collapsed position.

[0044]FIG. 10 is a perspective view of a portion of the ankleillustrating the locking mechanisms within the outer housing.

[0045] FIGS. 11A-11D provide detailed views of the components of thelocking mechanisms.

[0046]FIG. 11E provides a cross-sectional view of the ankle and thecomponents associated with the locking feature.

[0047] FIGS. 12A-12B are cross-sectional depictions of the balls andrings of the neck portion of the ankle wedged together to frictionallyhold the neck in position.

[0048] FIGS. 13A-13B illustrate an embodiment of a suction tube.

[0049]FIG. 14 shows the insertion of a suction tip into a suction tubereceptacle in a tissue engaging member.

[0050]FIGS. 15, 16, 17, 17A-17B illustrate an embodiment of an irrigatorof the present invention.

[0051]FIG. 18 illustrates an embodiment of the a handle of the presentinvention.

[0052]FIG. 19 illustrates the mechanisms within the handle which connectthe handle with the cable to hold the ankle in position.

[0053]FIG. 20 provides an end view of the handle illustrating exposureof the end screw for adjustment.

[0054] FIGS. 21-22 illustrate a cover handle which is pivotally attachedto the handle to assist in depressing the release button.

[0055]FIG. 23 is a perspective view of a first additional embodiment ofthe stabilizer.

[0056]FIG. 24 is a detailed elevation view of the stabilizer foot of thefirst additional embodiment.

[0057]FIG. 25 is a detailed plan view of the stabilizer foot of thefirst additional embodiment.

[0058]FIG. 26 is a detailed view of the underside of the stabilizer footof FIG. 25.

[0059]FIGS. 27A and 27B are section views of the ankle portion of thestabilizer foot showing the locking mechanism.

[0060]FIGS. 28A and 28B are section views of the external handle or baseportion of the stabilizer showing the quick-release mechanism in thefixed and released positions respectively.

[0061]FIG. 29 is a detailed view of the stabilizer foot as rotated tothe furled position to facilitate insertion or retraction.

[0062]FIG. 30 is a perspective view of the foot portion of a secondadditional embodiment of the stabilizer, showing the stabilizer toeportions rotated by the split ball mounting to the furled position.

[0063]FIG. 31 is a top view of the stabilizer of FIG. 30 showing thefurled toe portions superimposed on the stabilizer shaft, illustratingthe compact cross-sectional configuration of the furled stabilizer.

[0064]FIG. 32 is a side view of the foot portion of the stabilizer ofFIG. 30 also showing the toe portions in the furled position.

[0065]FIG. 33 is a top view of the foot portion of the stabilizer ofFIG. 30 showing the stabilizer toe portions in the deployed position.

[0066]FIG. 34 is a frontal elevation view of the stabilizing surfacesnested in an overlapping configuration within the overall diameter ofthe joint housing 98.

[0067]FIGS. 35A and 35B are longitudinal cross-sectional views of thesplit ball ankle portion of the stabilizer showing the split ballmechanism in the deployed and furled positions respectively.

[0068]FIGS. 36A and 36B are longitudinal cross-sectional views of thepush rod compression mechanism of the stabilizer, showing the handle orbase from the side and top respectively.

[0069]FIG. 37 is a section plan view of a third additional embodiment ofa stabilizer comprising a ball-joint ankle portion andtension-cable-actuated lockable toe portions.

[0070] FIGS. 38A-38B are a section plan view and elevation of a fourthadditional embodiment of a stabilizer comprising a ball-joint ankleportion and pushrod-actuated lockable toe portions.

[0071] FIGS. 39A-39B are a section plan view and elevation of a fifthadditional embodiment of a stabilizer comprising a ball-joint ankleportion and tension-cable/cam or gear-actuated lockable toe portions.

[0072]FIG. 40 and FIG. 40A are sixth additional embodiments illustratingstabilizer toe cleats.

[0073] FIGS. 41A-41B are section elevation views of a seventh additionalembodiment of a stabilizer comprising a quick-release and cabletensioning mechanism included in the handle, illustrated in the closedand released configurations.

[0074]FIG. 42 is a section elevation view of an eighth additionalembodiment illustrating an optional pneumatic cable tensioningmechanism.

[0075] FIGS. 43A-43C illustrate a ninth additional embodiment comprisinga positioning and clamping system for a beating heart stabilizer.

DETAILED DESCRIPTION OF THE INVENTION

[0076] The following detailed description illustrates the invention byway of example, not by way of limitation of the principles of theinvention. This description will clearly enable one skilled in the artto make and use the invention, and describes several embodiments,adaptations, variations, alternatives and uses of the invention,including what is presently believed to be the best mode of carrying outthe invention.

[0077] In this regard, the invention is illustrated in the severalfigures, and is of sufficient complexity that the many parts,interrelationships, and sub-combinations are most clearly ormeaningfully illustrated in a series of separate patent-type drawings.Accordingly, several of the drawings show in schematic, or omit, partsthat are not essential in that drawing to a description of a particularfeature, aspect or principle of the invention being disclosed. Thus, thebest mode embodiment of one feature may be shown in one drawing, and thebest mode of another feature will be called out in another drawing.

[0078] All publications and patent applications cited in thisspecification are herein incorporated by reference as if each individualpublication or patent application were specifically and individuallyindicated to be incorporated by reference.

[0079] Overview of Robotic Surgery Devices and Methods

[0080]FIG. 1 is a schematic plane view of a portion of an operating roomshowing by way of background an exemplary robotic surgical system 1performing a minimally invasive robotic surgical procedure. Such arobotic surgical system is described in Application No. PCT/US99/17,522,filed Aug. 3, 1999, entitled Manipulator Positioning Linkage For RoboticSurgery, published on Feb. 17, 2000 as WO00/07,503, the full disclosureof which is incorporated by reference.

[0081] Additional examples of robotic surgical systems, relatedapparatus and subsystems and surgical methods for use with the presentinvention are described in co-pending U.S. patent application Ser. No.09/433,120, filed on Nov. 3, 1999, entitled “Cooperative MinimallyInvasive Telesurgical System”, which was the basis for InternationalApplication No. PCT/US99/27,61, filed Nov. 18, 1999 and published as WO00/30548 on Jun. 2, 2000; and in co-pending U.S. patent application Ser.No. 09/373,678 entitled “Camera Reference Control in a MinimallyInvasive Surgical Apparatus,” filed Aug. 13, 1999. The full disclosureof each application is incorporated herein by reference.

[0082] Examples of both robotic and endoscopic beating heart stabilizersare described in co-pending U.S. patent application Ser. No. 09/436,524,filed Nov. 9, 1999, entitled “Stabilizer For Robotic Beating-HeartSurgey,” which was the basis for International Application No.PCT/US99/27,610, filed Nov. 18, 1999 and published as WO 00/30551 onJun. 2, 2000, both of which are assigned to the assignee of the presentapplication. The full disclosures of these applications are incorporatedby reference as if fully set forth herein.

[0083] An operator O (generally a surgeon) performs a minimally invasivesurgical procedure on patient P lying on operating table T, the operatorO manipulating one or more input devices or masters 2 at a surgeon'sconsole 3. In response to the surgeon's inputs, a computer processor 4of console 3 directs movement of endoscopic surgical instruments ortools 5, effecting servo-mechanical movement of the instruments via arobotic patient-side system 6 (a cart-mounted system in this example).

[0084] Typically, patient side system or cart 6 includes at least threerobotic manipulator arms. Two arms or linkages 7 (mounted at the sidesof cart 6 in this example) support and position servo-manipulators 8which drive surgical tools 5; and one arm or linkage 9 (mounted at thecenter of cart 6 in this example) supports and positionsservo-manipulator 10 which controls the motion of an endoscope/cameraprobe 11, which captures an image (preferably stereoscopic) of theinternal surgical site.

[0085] The image of the internal surgical site shown to operator O by astereoscopic display viewer 12 in surgeon's console 3, and issimultaneously shown to assistant A by an assistant's display 14.Assistant A assists in pre-positioning the manipulator 8 and 10 relativeto patient P, in swapping tools 5 in one or more of surgical manipulator8 (and/or 10) for alternative surgical tools or instruments 5′, inoperating related non-robotic medical instruments and equipment, and thelike.

[0086] In general terms, the arms or linkages 7, 9 comprise apositioning linkage or set-up arm portion of patient-side system 6,typically remaining in a fixed configuration while tissue ismanipulated, and the manipulators 8, 10 comprise a driven portion whichis actively articulated under the direction of surgeon's console 3. Theactively driven portion is herein generally referred to as a“manipulator”, and the fixable portion of the positioning linkage ofpatient-side system linkage is referred to herein as a “set-up arm”, itbeing noted that such setup arms may optionally have powered andcomputer controlled joints as described herein.

[0087] For convenience in terminology, a manipulator such as 8 actuatingtissue affecting surgical tools is generally referred to herein as a PSM(patient-side manipulator), and a manipulator such as 10 controlling animage capture or data acquisition device, such as endoscope 11, isgenerally referred to herein as a ECM (endoscope-camera manipulator), itbeing noted that such telesurgical robotic manipulators may optionallyactuate, maneuver and control a wide variety of instruments, tools anddevices useful in surgery.

[0088] Overview of Stabilizer of Present Invention

[0089] The present invention is particularly useful in performingminimally invasive robotic coronary artery bypass graft (CABG)procedures. As illustrated in FIG. 2, the heart H remains beating and isaccessed through a body wall BW, with robotically operated surgicalinstruments 1010 introduced through access sheaths or cannulas 1012. Itmay be appreciated that such a stabilizer 1000 may be used to stabilizeany body tissue or organ other than the heart. In these cases, therobotic surgical instruments 1010 would be inserted through any bodywall BW, such as the chest wall, abdominal wall, or like. Theinstruments 1010 may be positioned by pivoting the instruments 1010about insertion points through the body wall BW by axial movement of theinstruments 1010 through the cannulas 1012, rotation of the instruments1010 about their axes, and articulation of the instruments 1010. When acoronary artery CA is the targeted for anastomosis, a surgical worksite1014 is identified surrounding the coronary artery CA. Since the heartis beating, the surgical worksite 1014 is in motion. Such motion isinhibited by engaging a surface of the heart H, preferably in the areaof the surgical worksite 1014, with a stabilizer 1000.

[0090] It should be understood that the stabilizer 1000 need notcompletely prevent motion of surgical site 1014. Force is applied to thestabilizer 1000 through downward pressure or tensioning of internalcables such that the stabilizer inhibits motion of the surgical worksite1014 in at least one direction, and ideally in a plurality ofdirections. As explained more fully in co-pending U.S. patentapplication Ser. No. 09/436,982, filed Nov. 9, 1999, entitled“Performing Cardiac Surgery Without Cardioplegia”; the full disclosureof which is incorporated herein by reference, residual motion ofsurgical worksite 1014 may optionally be accommodated by the roboticsurgical system by tracking the remaining motion and maintainingalignment between the surgical tools 1010 and the movement of thesurgical worksite 1014. Advantageously, the heart may be tolerant of theforces involved in reducing motion of the surgical worksite as comparedto attempts to completely cease motion.

[0091] Referring to FIG. 3, an embodiment of the stabilizer 1000 isshown stabilizing the surgical worksite 1014. In this embodiment, thestabilizer 1000 comprises a narrow elongate shaft 16 mounting astabilizer distal portion or foot 17. The foot 17 comprises a jointedportion or ankle 18 connected with a pair of stabilizer bodies or toeportions 19. As will be described in a later section, the toe portions19 are actuated and locked in a selected deployment position by atension cable 20 (not shown). Mounted on each toe portion 19 is astabilizing surface or tissue engaging member 22. Suction tubes 240,inserted through suction lumens 210 in the shaft 16 so as to extenddistally through shaft face 220, connect with each tissue engagingmember 22. Suction is provided through suction holes 1020 along theengaging member 22. Such suction holds the stabilizer 1000 in firmcontact with the worksite 1014. In addition, an irrigation conduit 312is inserted through an irrigation lumen 214 in the shaft 16. The conduit312 is manipulable to direct fluid or gas to the worksite 1014 or anydesired location.

[0092] As shown in FIG. 3, the members 22 are typically positioned tostraddle the coronary artery CA or vessel of interest. To prepare thecoronary artery CA for anastomosis, the coronary artery CA is isolatedfrom blood flow by cinching the coronary artery CA upstream anddownstream of the desired location for anastomosis. Thus, when theanastomosis is made, blood will not flow out into the workspace. Thecoronary artery CA may be isolated by any known or suitable method.Likewise, according to the present invention, the coronary artery CA maybe isolated with the use of flexible members 502 which are tied tovessel occlusion fasteners or fastening clips 350. Each flexible member502 is passed under and around the coronary artery CA, as shown, usinginstruments 1010 inserted within the chest cavity. Each flexible member502 is then tightened and held by a fastening clip 350, as will bedescribed in further detail.

[0093] FIGS. 4A-4E illustrate an embodiment of a fastening clip 350 ofthe present invention. In the example shown, the clip 350 is configuredto attach to two portions of a flexible member 502, such as in creatinga loop. In one embodiment, the clip 350 comprises a generally elongateplate-like body 351, which may be rectangular as shown. The body 351 hasat least one hole or bore 352 which intersects a radial slot 354. Thebore 352 and slot 354 having a depth axis parallel to one another. Inthe example shown, the body 351 has a first bore 352 a and a second bore352 b with respective slots 354 a, 354 b which lie outboard (towards theplate ends) from their respective bores 352 a, 352 b.

[0094] As best seen in FIG. 4A, the flexible member 502 is held withinslot 354 a. The member 502 may be held by any suitable means. Forexample, a locking pin 356 may be inserted in a transverse aperture 358which passes across the bore 352/slot 354 intersection on one side ofthe clip 350, thus mechanically preventing the member 502 from movingback into the bore 352. The locking pin 356 may be sized to press-fitsecurely in aperture 358, may be bonded to body 350, or may bepermanently or releasably fixed within aperture 358 by known means. Theflexible member 502 is then passed under and around the coronary arteryCA and threaded through the bore 352 b in the direction of arrow T1, thebore 352 diameter (d1) being selected sufficiently larger than themember 502 diameter to permit suitable clearance. The member 502 maythen be fixed in place by sliding the member 502 laterally from the bore352 b into the slot 354 b in the direction of arrow T2. The slot width(d2) is selected to be sufficiently smaller than the member diameter soas to compress and deform the portion of the member 502 contained in theslot, thereby creating substantial frictional forces to prevent themember 502 from being pulled out of the slot in the direction of arrowT3. The friction also resists inadvertent lateral movement of the tubeback into the bore 352.

[0095] The relationship of the sizes of the flexible member 502, bore352 and slot 354 is a function of the degree of frictional resistancedesired, and may be varied to suit different materials and memberconstructions. In one preferred example, the clip 350 has a length (x1),width (x2) and depth (x3) of about 0.31, 0.1 and 0.05 inches (about 7.9,2.5 and 1.3 mm) respectively, has a bore diameter (d1) of about 0.05inches (1.3 mm), and a slot width (d2) of about 0.01 inches (0.25 mm).

[0096] The flexible member 502 may comprise silicone tubing or otherflexible material. The flexible member is preferably large enough tocatch in the slots 354 but not so large as to require large penetrationsabout the coronary artery CA or to be ineffective in occluding theartery CA. For exemplary clips 350 having a slot 354 with a width ofabout 0.010 inches, a preferred Silastic tubing has an outer diameter ofabout 0.050″ and an inner diameter of 0.030″, such as that availablefrom QUEST MEDICAL of Allen, Tex. under the product name“Retract-O-Tape”. Alternative elastic and inelastic flexible members502, such as suture material and the like may also be used. The flexiblemember 502 is tied off to clips 350 using instruments 1010 in anendoscopic procedure, while the heart H is beating and without any needfor a thoracotomy or a mini-thoracotomy.

[0097] In a preferred embodiment of the clip 350 for vessel occlusion,the member 502 and clip 350 are provided in a sealed package as anpre-assembled, sterilized disposable unit, in which the member 502 islocked into the slot 352 at one end by pin 356, with the other memberend free. The tube may be pre-assembled with a suturing needle fixed tothe free end.

[0098] Once clips 350 have been placed as shown in FIG. 3, the free endsof the members 502 may be tightened by pulling the slack and thereforeconstricting and occluding the coronary artery CA. After the members 502have been fixed within the clip slots 354, the clips 350 may be left inplace to occlude the coronary artery CA. The stabilizer 1000 may then berepositioned without disturbing the occlusion assembly of member 502 andclip 350. The coronary artery CA is thus stabilized, isolated and readyfor the CABG procedure using the robotic surgical instruments 1010.

[0099]FIG. 5 provides a full view of an exemplary embodiment of thestabilizer 1000. As shown, the stabilizer 1000 comprises a narrowelongate shaft 16 mounting a stabilizer distal portion or foot 17. Thestabilizer 1000 is shown in an approximate correct scale for an typicalinstrument having a shaft 16 of approximately 12 mm diameter. The foot17 comprises a jointed portion or ankle 18 connected with a pair ofstabilizer bodies or toe portions 19. Mounted on each toe portion 19 isa stabilizing surface or tissue engaging member 22. Suction tubes 240,inserted through suction lumens 210 in the shaft 16 so as to extenddistally through shaft face 220, connect with each tissue engagingmember 22. Suction is provided through suction holes 1020 along theengaging member 22. In addition, an irrigation conduit 312 is insertedthrough an irrigation lumen 214 in the shaft 16. The conduit 312 ismanipulable to direct fluid or gas to the worksite 1014 or any desiredlocation. The proximal portion 202 of the stabilizer 1000 includes anadjustable cable tensioner 204, which comprises a handle 206 actuatingratchet mechanism 208 which in turn adjustably engages cable 20 (notshown). As will be described in a later section, the toe portions 19 areactuated and locked in a selected deployment position by the cable 20.

[0100] FIGS. 6A-6B illustrate an embodiment of a positioning andclamping system 170 for the stabilizer 1000 when used in minimallyinvasive surgery, optionally robotic surgery. The system 170 comprises alinkage of a plurality of lockable-releasable joints mounted on a base171 which is rigidly fixed to the side rail of an operating table T orsimilar support. In the example shown, the linkage includes a verticallink 172 joined by 1-degree of freedom rotating joint 173 to ahorizontal link 174. Link 174 is in turn joined by 2-degree of freedomjoint 175 to descending link 176. Link 176 is in turn joined to clamp177 by a 3-degree of freedom joint 178, such as a lockable ball joint.Clamp 177 adjustably clamps the shaft of stabilizer 1000, which isinserted into the chest of a patient P lying on the table T.

[0101] Note that all joints of clamping system 170 are lockable torigidly hold stabilizer 1000. The elements of the stabilizer may bepositioned against the tissue to be stabilized using roboticallyoperated surgical instruments 1010 (such as tissue graspers, needlegraspers, forcepts or the like, see FIG. 2) and then locked in thedesired configuration. Greater or lessor degrees of freedom at eachjoint are feasible. In addition, each link may be made to lockablytelescope, to permit adjustment of link length. The joints may bearranged to all lock/release by means of a single control, or may bearranged to lock in a pre-determined sequence. The joints may each havea selected degree of residual friction in the unlocked state, to assistin manual positioning. The joints may have position encoders, lockingstatus encoders, and pneumatic locking actuators. Additionally oralternatively, the clamp 177 may clamp and position the insertioncannula 1012 (not shown). Various alternative balancing mechanisms maybe optionally included to counteract the force of gravity in each link.

[0102] Description of the Toe Portions of the Stabilizer

[0103] FIGS. 7A-7B illustrate an embodiment of the toe portions 19 ofthe foot 17 of the stabilizer 1000. Generally, the foot 17 comprises atleast two toe portions 19, each portion 19 having a stabilizing surfaceor tissue engaging member 22 thereattached. FIG. 7A shows a top view ofthe toe portions 19 which are generally comprised of a smooth surface.FIG. 7B shows a bottom view of the toe portions 19 revealing theunderside of the tissue engaging members 22. The underside of themembers 22 have one or more suction ports 1030. Suction is provided tothe suction ports 1030 by a suction tube 240 (not shown) which connectswith the member 22 by insertion of the tube 240 into a suction tubereceptacle 1032. Generally, a separate suction tube 240 is inserted intoa suction tube receptacle 1032 in each member 22.

[0104] The toe portions 19 are shaped and arranged so that the tissueengaging members 22 are generally parallel and spaced apart to permitsurgical access to the surface of the heart therebetween. For example,the toes may be spaced from about 5-30 mm apart, preferably about 10-15mm apart, adequate spacing to straddle a coronary artery CA of interest.As shown in FIG. 8, the toe portions 19 are joined in a toe assembly1040 which allows the portions 19 and associated members 22 to collapseor rotate inward, reducing the space between the members 22 and allowingthe foot 17 to be inserted through a cannula 1012. In this embodiment,the toe assembly 1040 comprises a top ball shell 1041, a first toeportion 1042, a torsion spring 1044, a second toe portion 1046, a bottomball shell 1048, and a rivet 1050 which is insertable through the abovecomponents of the assembly 1040 to hold them in place. As shown, the toeportions 1042, 1046 each comprise a tissue engaging member 22, a strut1052 and a ring mount 1054. The member 22, strut 1052 and ring mount1054 may be molded or formed so as to comprise one continuous piece, orsome or all of these may be joined to each other. Generally, onecontinuous piece provides more strength and resistance to fatiguefailure.

[0105] The components of the assembly 1040 are assembled as shown inFIG. 8, wherein the ring mount 1054 of the first toe portion 1042 fitswithin the top ball shell 1041 and its strut 1052 fits within a strutnotch 1056. The torsion spring 1044 fits within a ring notch 1058 oneach ring mount 1054 of the first and second toe portions 1042, 1046.And, the ring mount 1054 of the second toe portion 1046 fits within thebottom ball shell 1048 and its strut 1052 fits within its strut notch1056. Together, the assembly 1040 provides a spring-loaded, collapsiblepair of toe portions 1042, 1046 which are joined at one end to form aspherical split ball shell 1041, 1048. The split ball shell 1041, 1048is joined with the ankle 18, as shown in FIG. 9A. The split ball shell1041, 1048 of the assembly 1040 is disposed within the housing 1070 sothat the assembly 1040 is freely rotateable.

[0106] FIGS. 9B-9K illustrate an embodiment of how the toe portions1042, 1046 may collapse from a deployed or expanded position to a furledor collapsed position for insertion through a cannula. FIG. 9B is aperspective view of the toe portions 1042, 1046 in the deployedposition. FIG. 9C is a plan view of the toe portions 1042, 1046, FIG. 9Dis a rear elevation view of the toe portions 1042, 1046, FIG. 9E is aside elevation view of the toe portions 1042, 1046 and FIG. 9F is afrontal elevation view of the toe portions 1042, 1046, all in thedeployed position. By rotating the toe portions 1042, 1046 within thetop ball shell 1041 and bottom ball shell 1048, the toe portions 1042,1046 may collapse to a furled position illustrated in FIG. 9G. FIG. 9His a plan view of the toe portions 1042, 1046, FIG. 91 is a rearelevation view of the toe portions 1042, 1046, FIG. 9J is a sideelevation view of the toe portions 1042, 1046 and FIG. 9K is a frontalelevation view of the toe portions 1042, 1046, all in the furledposition. It may be appreciated that the toe portions 1042, 1046 maycollapse in a variety of arrangements and FIGS. 9B-9K serve toillustrate an embodiment of such arrangements.

[0107] Description of the Ankle of the Stabilizer

[0108] Referring again to FIG. 9A, the assembly 1040 is joined with theankle 18 in this embodiment as shown. Here, the ankle 18 comprises anouter housing 1070 which is connected with an adjustable neck 1072. Theneck 1072 is in turn connected with the shaft face 220 of the shaft 16.As shown, the shaft face 220 includes ports to access the suction lumens210 and irrigation lumen 214, to name a few. As previously described,the split ball shell 1041, 1048 of the assembly 1040 is disposed withinthe housing 1070 so that the assembly 1040 is freely rotateable. Inaddition, the adjustable neck 1072 of the ankle 18 allows the housing1070 and therefore assembly 1040 to move in all six degrees of freedomrelative to the shaft 16.

[0109] Once the assembly 1040 has been positioned in a desiredorientation, the assembly 1040 and ankle 18 may be locked in place.Referring to FIG. 10, such locking may be achieved with the use of alocking ball 1076 which is disposed within an inner housing 1078, boththe ball 1076 and inner housing 1078 of which are disposed within theouter housing 1070 as shown. Pins 1074 are fixedly attached to the outerhousing 1070 and pass from one side of the housing 1070 to the other,passing adjacent to portions of the inner housing 1078.

[0110] FIGS. 11A-11D provide more detailed views of the components ofthe locking mechanisms. FIG. 11A illustrates the position of the lockingball 1076, in dashed line, relative to the spherical split ball shell1041, 1048 of the assembly 1040 within the outer housing 1070. The innerhousing 1078 and other components have not been included in this viewfor clarity. FIGS. 11B-11D provide an exploded view of the additionalcomponents to illustrate how they fit together.

[0111]FIG. 11B illustrates a slide bearing 1080 having a central bore1081 and a hemispherical mating surface 1082. The locking ball 1076 ispositioned so that it is mateable against the hemispherical matingsurface 1082 and the cable 20 passes through the central bore 1081 asshown. The slide bearing 1076 also includes pin apertures 1074 a throughwhich pins 1074 are fittable as illustrated by arrows.

[0112]FIG. 11C illustrates the inner housing 1078 having a slot 1084 anda hemispherical mating surface 1079. The slide bearing 1080 and lockingball 1076 fit within the slot 1084 of the inner housing 1078, asindicated by dashed lines.

[0113]FIG. 11D illustrates the outer housing 1070 having a bore 1086 andan end slot 1083 as shown. In addition, the housing 1070 has pinapertures 1074 b which pass from one side of the outer housing 1070 tothe opposite side 1070 side of the outer housing 1070. The inner housing1078 fits within the bore 1086 of the outer housing 1070, as indicted bydashed lines. The pin apertures 1074 a align with pin apertures 1074 bso that pins 1074 may be passed through the apertures 1074 a, 1074 b andfixed in place by pressure fitting, threads, bonding or other knownmeans. Thus, in the assembled ankle 18, the pins 1074 serve to fixedlyconnect the slideable member 1080 to the outer housing 1070. However,the slot 1084 within the inner housing 1078 provides sufficientclearance so that the inner housing 1078 is free to move slightly in anaxial direction within bore 1086 when the cable 20 is relaxed. This isone aspect which allows movement of the ankle 18 when the cable 20 isrelaxed. The spherical split ball shell 1041, 1048, as illustrated indashed line, is received within the end slot 1083 and is mateableagainst hemispherical mating surface 1079.

[0114]FIG. 11E provides a cross-sectional view of the ankle 18 and thecomponents associated with the locking feature. As shown, the lockingball 1076 is attached to a tension cable 20 which extends through theneck 1072 and along the shaft 16. The locking ball 1076 is disposedagainst the slide bearing 1080, within the inner housing 1078 and theouter housing 1070, and can freely move within the inner housing 1078when the adjusting the ankle 18. The pins 1074 are fixedly attached tothe outer housing 1070 and pass through the slide bearing 1080 so thepins 1074, slide bearing 1080 and outer housing 1070 are moveable as aunit as identified by shading. The spherical split ball shell 1041, 1048of the assembly 1040 is disposed within the outer housing 1070 as shownso that the shell 1041, 1048 and the locking ball 1076 are separated bythe hemispherical mating surface 1079 of the inner housing 1078. Theshell 1041, 1048 can freely move between the inner housing 1078 andouter housing 1070 when adjusting the ankle 18 or assembly 1040.

[0115] In this embodiment, the neck 1072 is comprised of a series ofinterlocking balls 36 and intermediate socket rings 37. The balls 36each have a hollow core through which extends the distal portion of thecable 20. Joints between the balls 36 and the rings 37 may be sealed bythe rings or may alternatively or additionally have an outer covering ofa flexible material, such as an extruded heat-shrinkable polymericmaterial. Each ball 36 may be rotated independently against an adjacentring 37 to allow the neck 1072 to be positioned. Once the neck 1072 andthe assembly 1040 are positioned, they may be locked in place byapplying tension to the cable 20 in the direction of arrow 1080.

[0116] As cable 20 is tensioned, the outer housing 1070 moves slightlyproximally relative to the inner housing 1078, urging the sphericalsplit ball shell 1041, 1048 into frictional contact with thehemispherical mating surface 1079. As the shell 1041, 1048 bears uponinner housing 1078, the inner housing 1078 in turn bears upon one ormore of the balls 36 and intermediate sockets rings 37 of the ankle 18.By continuing to apply tension to the cable 20, the locking ball 1076and shell 1041,1048 are eventually held tightly and restricted amovement. Thus, it may be seen that when the cable 20 is tensioned, thetension force is communicated sequentially by joint contact forces fromlocking ball 1076 to slide bearing 1080 to outer housing 1070 to shell1041,1048 to inner housing 1078 and finally to the balls 36 and socketrings 37. The mechanical reaction force which balances the tension forceon cable 20 is provided by the contact of the most proximal ball joint36 which is fixedly mounted to shaft face 220. The contact forces sogenerated provide a frictional resistance to rotational movement at eachof these joints, causing the foot assembly to become lockedjoint-by-joint throughout.

[0117] Note that although the mating surfaces of the contacting elementssuch as balls 36, and socket rings 37 are exemplified above as being ofa generally spherical contour, other alternative surface contours arefeasible and may be desirable. FIG. 12A illustrates an embodiment of aportion of the neck 1100 showing the balls 36 interlocked with the rings37. Here, a generally hemispherical surface 1104 of ball 36 mates with agenerally hemispherical surface 1102 of socket ring 37 over a somewhatdistributed contact area, since surface 1104 approximately conforms inshape to surface 1102. When the neck 1072 is placed in compression (suchas by applying tension to a central tension cable, not shown), thesummation of forces over the contact area tends toward the centerline ofthe neck 1072, and may be represented by arrow 1084, acting at an angleθ. In this example, the angle θ is typically about 40 degrees for thecontour of the surface 1104.

[0118] In an alternative embodiment a portion of the neck 1101, as shownin FIG. 12B, a generally hemispherical surface 1103 of alternative ball36′ contacts a generally conical surface 1105 of alternative socket ring37′. Due to the contours of the surfaces 1103, 1105, the surfaces 1103,1105 have considerably more concentrated contact area. This is becausesurface 1103 becomes approximately tangent to surface 1105 only at anarrow region of tangency. Thus, when assembly 1101 is placed incompression, the summation of forces over the contact area is restrictedto the region of tangency, as represented by arrow 1085, acting at anangle θ′. The angle θ′ of the region of tangency may be adjusted bysuitably selecting the conical angle α of surface 11 05. In the exampleof FIG. 12B, the conical angle a may be about 20 degrees and the angleθ′ may be about 69 degrees.

[0119] Due to the generally hemispherical contour of surface 1103, thealternative embodiment of the portion of the neck 1101 will have asimilarly shaped tangent region between ball 36′ and socket ring 37′ inthe event that these elements are rotated out of the parallel alignmentshown in FIG. 12B.

[0120] Note that the contact between a hemispherical surface(approximated in this example by surface 1103) and a conical surface(approximated in this example by surface 1105) may be idealized as acircle perpendicular to the center axis, although a real structure willreact to applied contact forces over a region of finite area, the shapeof which may be a function of surface irregularities, materialproperties, deformations and the like.

[0121] In addition, although in the preferred embodiments the surfaces1102, 1103, 1104, 1105 may be axially symmetrical surfaces ofrevolution, they need not necessarily be so, such as, for example, whereit is desired to limit motion within the neck portions 1100 or 1101 to asingle degree of rotational freedom.

[0122] As mentioned above, the larger contact angle θ′ of neckembodiment 1101 provides a stronger locking frictional force resistingrotation about the joint than is provided by the smaller contact angle θof neck embodiment 1100, for a given overall neck diameter andcompression force. The relationship between the angle θ and θ′ and theapplied perpendicular breakaway force for the joint may be approximatedby the following formula:

Fa=μF _(t) R/(2dCos θ)

[0123] where:

[0124] Fa=breakaway force (locking effect)

[0125] F_(t)=tension force on cable (causing joint compression)

[0126] R=joint radius (e.g., hemispherical radius)

[0127] d=lever arm of applied Fa from joint center (e.g., distance fromtoe to joint center).

[0128] θ=coefficient of static friction (function of materialproperties, lubrication effect of body fluids, etc.)

[0129] Thus the relative breakaway force for the two exemplaryembodiments shown in FIGS. 12A and 12B is approximately proportional tothe inverse ratio of cosines the contact angles or:

Fa′/Fa=Cos θ/Cos θ′=Cos(40°)/Cos(69°)=2.14

[0130] Thus it may be seen that the alternative neck embodiment 1101 hasa substantially enhanced locking effect relative to neck embodiment1100, given comparable operative conditions.

[0131] A suction-enhanced beating heart stabilizer may be constructedfor surgery performed via a large sternotomy which is held open by asternal retractor. See, for example, Borst et al., U.S. Pat. No.6,015,378, the disclosure of which is incorporated herein by reference.In a stabilizer intended for this purpose having cable-locked ball andsocket type joints, the locking force may be increased by selecting alarger ball joint assembly, sized to provide a desired breakaway forcefor a selected cable tension.

[0132] However, in minimally invasive cardiac surgery, such largeincisions and accompanying tissue damage are desirably avoided, and thestabilizers embodiments of the present invention may be of a sizesuitable for insertion through a small cannula placed in a small bodywall incision, such as in the intercostal space between ribs. For thispurpose, the joint size is preferably kept small. Thus, the ability ofthe alternative neck embodiment 1101 to provide a large locking forcewithin the small joint diameter particularly suits it for use ininstrumentation intended for minimally invasive or endoscopic surgery.

[0133] Description of the Suction Tubes

[0134] Suction tubes 240 are insertable through suction lumens 210 inthe shaft 16, as previously shown in FIG. 3 and FIG. 5, so as to extenddistally through shaft face 220. FIGS. 13A-13B illustrate an embodimentof a suction tube 240. As shown in FIG. 13A, the suction tube 240 has anelongated shape with a stopper portion 242 at proximal end 1092 and aflexible portion 244 at distal end 1094. FIG. 13B is an enlarged view ofthe flexible portion 244. The tubes 240 may be made to be disposable ormay be readily sterilizable for reuse. Typically, the flexible portion244 is made from a flexible polymer, which may optionally becoil-reinforced as shown to prevent kinking and suction collapse. Thesuction tube 240 includes a suction tip 1090 disposed at the distal end1094 having one or more suction holes 1020.

[0135] The suction tip 1090 is insertable through a lumen port 210 b,shown in FIG. 5, and through the suction lumen 210 until the stopperportion 242 frictionally engages and seals to the lumen port 210 b. Atthis point, the suction tip 1090 protrudes through the shaft face 220.As shown in FIG. 14, the suction tip 1090 is then insertable into thesuction tip receptacle 1032 in the tissue engaging member 22. Note thatthe entry to the receptacle 1032 may have thread-like grooves to “snapfit” to reinforcment coils 1097 at the end of portion 240. Thereceptacle 1032 extends along the member 22, passing through the suctionports 1030. Generally, the tip 1090 is positioned so that the suctionholes 1020 align with the suction ports 1030. As described previously,suction is provided through the suction holes 1020 along the engagingmember 22. Such suction holds the stabilizer 1000 in firm contact withthe worksite 1014.

[0136] Description of the Irrigator

[0137]FIGS. 15, 16, 17, 17A-17B illustrate an embodiment of anirrigation device or irrigator 310 as previously shown in FIG. 3. Theirrigator 310 is insertable through the irrigation lumen 214 in theshaft 16 of the stabilizer 1000 so that it protrudes outwardly from theshaft face 220. Fluids, such as liquids or gases, may be delivered tothe worksite 1014 through the irrigator 310 as needed. The fluids may beused for a number of surgical purposes, such as to remove blood from theanastomotic site. For example, the irrigator 310 may be positioned by asurgeon so that it is adjacent an anastomosis site, leaving clearancefor working tools, and a flow of saline solution may be adjusted toprovide a steady drip to remove blood and the like. Alternatively, aflow of carbon dioxide may be established to blow liquids away from thesurgical site.

[0138] In the embodiment illustrated in FIG. 15 and FIG. 16, theirrigator 310 comprises an elongate (and preferably somewhat flexible)conduit 312 and a flexibly adjustable dispenser 314. The dispenser 314terminates in a nozzle or spout portion 316. In this embodiment, theirrigator 310 also includes a mounting plug or lumen connector 318 and afluid supply connector 320 in communication with conduit 312.

[0139] The diameter or width dimensions of conduit 312 is selected to beinsertable into and through the lumen 214 in the stabilizer shaft 16. Asthe conduit 312 is fully inserted into the lumen 214, the spout portion316 extends through the distal lumen opening in shaft face 220.Preferably, the diameter or width of the dispenser 314 and nozzle 316 isalso selected to be insertable through lumen 214 (note that dispenser314 preferably may be straightened for convenient insertion).

[0140] In a preferred embodiment, the irrigator 310 is provided in asealed package as an pre-assembled, sterilized disposable unit, and isinserted in and mounted to the separately-sterilized stabilizer 1000during surgical preparation. The irrigator 310 preferably comprises aconventional biocompatible polymer material. Alternatively, theirrigator 310 may be installed in the stabilizer 1000 in separatecomponents, which are coupled after the conduit is inserted into lumen214, e.g., dispenser 314 may be coupled to conduit 312 after the conduitis inserted in lumen 214.

[0141] As illustrated in FIG. 17 and FIGS. 17A-17B, the adjustabledispenser 314 preferably comprises an “snap bead” type assembly,including a plurality of sub elements or “beads” 322, coupled end-to-endin chain-like fashion. Each substantially identical “bead” sub-elementincludes a proximal socket portion 324, a distal ball portion 326, andan internal longitudinal conduit portion 328 open at both ends. The ball326 is of a size selected to “snap-fit” into the conforming-shapedsocket portion 324 of the adjoining bead 322, the beads 322 preferablycomprising a molded, elastic polymer material. The shape of the ball 326and socket 324 is configured to form a ball-and-socket joint betweeneach pair of adjacent beads 322, so as to provide a substantiallyeffective fluid seal while permitting a substantial range of rotationalmotion in two degrees of freedom.

[0142] The “snap-fit” dimensions are preferably selected so as toprovide a secure chain assembly and also substantial residual normalforce between the inner surface of socket 324 and the outer surface ofball 326, so as to create frictional resistance to rotational movementbetween adjacent beads 322. The rotational freedom allows the shape ofthe dispenser 314 to be conveniently adjusted, e.g., by a surgeon usinga robotic end effector such as a forceps, while the frictionalresistance causes the adjusted shape of dispenser 314 to remain fixedafter it is released by the surgeon. The inter-communicating conduitportions 328 of the beads 322 form a continuous lumen from conduit 312to nozzle 316.

[0143] Optionally, alternative adjustable-shape tubular elements knownin the art may be included in the dispenser 314. However, the preferredball-and-socket dispenser 314 described herein has been found to providea conveniently and precisely adjustable member which is stable and haslittle or no “spring-back”, i.e., it “stays where the surgeon puts it”.This eliminates trial-and-error effort and time consumption duringadjustment due to springiness and over-correction, and allows thedispenser 314 to be quickly repositioned as desired to suit changingsurgical requirements.

[0144] Optionally, a thin, flexible tether filament 330 may be includedpassing longitudinally along the axis of the dispenser 314, e.g., beingfixed at one end to nozzle 316 at a mount 331 and extending through thecentral lumen of dispenser 314 into conduit 312. The tether 330 may befixed at its other end to a convenient point (not shown) along theconduit length or proximal to the conduit.

[0145] A conventional fluid supply may be coupled to connector 320. Thefluids may include liquids (e.g., saline solution, and the like) orgases (e.g., insufflation gas, carbon dioxide, and the like). The fluidflow rate may be controlled by conventional fluid supply controls, suchas valves and the like.

[0146] The irrigator of the invention may also be mounted to supports orinstruments other than the stabilizer 1000, and used where ever anadjustable endoscopic dispenser of surgical fluids is desired. It hasbeen found that the convenient and repeatable adjustability of theirrigation dispenser 314 permits it to be used additionally oralternatively to direct fluids on to surgical accessories, such as toclear blood or other substances from an endoscope objective element, andthe like.

[0147] Description of the Handle

[0148] As previously described, the ankle 18 of the stabilizer 1000 maybe positioned against the target worksite 1014 by manipulation with theuse of robotic surgical instruments 1010 within the chest cavity. Oncethe stabilizer 1000 has been positioned, the ankle 18 may be locked inplace to prevent movement of the toes 19 and to maintain properorientation of the stabilizer 1000. As mentioned, such locking isachieved by applying tension to the cable 20 which passes through theshaft 16 to the ankle 18 where it is attached to the locking ball 1076.Such tension is applied to the cable 20 by actuating a cable tensionerassembly 204 on the stabilizer 1000.

[0149]FIG. 18 illustrates an embodiment of the cable tensioner assembly204 of the present invention, shown at the proximal end of the shaft 16.The cable tensioner 204 comprises a pivotal handle 206 and ratchetmechanism 208. FIG. 19 illustrates the mechanisms within the handle 206which connect the handle 206 with the cable 20. As shown, the handle 206is pivoted to body 202 at pivot pin 222 and has an inboard portion 230which is attached to cable 20. Thus, as handle 206 is rotated downwardin the direction of arrow T1, the tension applied from pivot pin 222 toinboard portion 230 causes the cable 20 to be stressed and retractedupward in the direction of arrow T2. Ratchet pawls 224 are pivoted abovehandle 206 to engage surface 226, so as to lock the cable tensioner 204by preventing handle 206 from pivoting upwards. The cable tension at anygiven position of handle 206 can be adjusted by end screw 232, which isthreaded to a terminus of cable 20 and bears on the attachment 230 so asto adjust cable tension. FIG. 20 provides an end view of the handle 206illustrating exposure of end screw 232 for adjustment.

[0150] The cable 20 is released by pressing a release button 228 alocated on the handle 206, as illustrated in FIGS. 18-19. By pressingthe release button 228 a, the surgeon or assistant can quickly releasethe cable tension for removal or repositioning of the stabilizer 1000.The release button 228 a is mechanically linked (linkage not shown) torelease actuator 228 b, which pushes the pawl 224 away from ratchettoothed surface 226 when button 228 a is depressed, so as to allow thehandle 206 to be released. To assist in depressing the release button228 a, some embodiments include a cover handle 1098 which is pivotallyattached to the handle 206, as illustrated in FIG. 21 and FIG. 22. Bysqueezing the cover handle 1098 against the handle 206, the underlyingrelease button 228 a is depressed. This simply allows the lever actionof the cover handle 1098 to apply a stronger force to the button 228 a.In some embodiments, the cover handle 1098 is built into the handle 206.

[0151] The employment of a single-handle cable tensioner 206 leavessubstantial volume of body 202 free for routing of one or more supplylumens for such purposes as suction, irrigation, and insertion ofsurgical accessories. In the example shown in FIG. 20, there are fourlumens, two suction lumens 210, an accessory insertion lumen 212 and anirrigation lumen 214, each with a corresponding access port in theproximal end or face of body 202. The lumens each extend within shaft 16(which also houses tension cable 20) to a distal port in the distal face220 of shaft 16. The accessory insertion lumen may be used to insertvarious surgical devices, such as clamps, retractors, a holding deviceto support a graft vessel (e.g. internal mammary artery (IMA)), or thelike.

[0152] Additional Embodiments

[0153] Additional embodiments of the present invention illustratealternative or additional aspects of the stabilizer described above.Although only a limited number of such embodiments are described, it isunderstood that such description is not intended to limit the scope ofthe present invention.

[0154] Additional Embodiment #1

[0155]FIG. 23 illustrates a first additional embodiment of thestabilizer. FIG. 23 provides a perspective over-all view of thestabilizer 15, which includes the elongate shaft 16 and stabilizerdistal portion or foot 17. Again, the foot 17 comprises the jointedportion or ankle 18 connected with the pair of stabilizer bodies or toeportions 19. Also, the toe portions 19 are actuated and locked in aselected deployment position by the tension cable 20. Each toe 19 inturn mounts on of a pair of stabilizing surface or tissue engagingmembers 22, 22.

[0156] In this embodiment, the stabilizer 15 includes an adjustablecable tensioner 23, which comprises an internally threaded manual knob24 engaging an externally threaded proximal cable junction 26. The knob24 bears on a thrust bearing 28 which is mounted to the base of aproximal shaft housing 30. The cable 20 may be adjustably tensioned byturning the knob 24 to retract cable 20 until a selected tension isreached. A quick-release mechanism 32 is included in the proximal shafthousing 30 to permit toe 19 positioning. The cable 20 may be quicklyloosened from a pre-set tension so that the toe 19 is moveable andpositionable. The cable 20 may then be re-tensioned to substantially thesame pre-set tension without turning knob 24 so that the toe 19 is againfixed in place. The details of this quick-release mechanism 32 will bedescribed later in relation to FIGS. 28A-28B.

[0157]FIG. 24 is a detailed view of the stabilizer foot 17 and distalportion of shaft 16, showing the structure of the ankle 18 in thisembodiment. Here, the ankle 18 comprises one or more (preferably about3-4) sets of balls 36 engaged in intermediate socket rings 37. The mostproximal ball 36 engages shaft end cap 38 and the most distal ballengaging toe mount housing 40. The balls 36 each have a hollow corethrough which extends the distal portion of tension cable 20. The cable20 is bifurcated into connector cables 21, which extend through toehousing 40 to couple with the toes 19. Note that the stabilizingsurfaces 22 preferably each include a pair of grooves or cleats 42 forreleasably securing flexible members 502 during surgery.

[0158]FIG. 25 provides a detailed view of the stabilizer foot 17. Inthis example, a single vacuum source tube 43 extends through shaft 16 toa vacuum plenum 46 in shaft distal end cap 38. The plenum 46communicates with a pair of vacuum conduits 48 which connect to thestabilizing surfaces 22. The conduits 48 may be composed of a flexiblepolymer, optionally with internal stiffening coils to resist collapse.Alternatively, individual vacuum source tubes may be provided for eachstabilizer surface 22, and alternative embodiments may have entirelyinternal vacuum source routing.

[0159] Also shown in this example is an irrigation fluid supply tube 44which extends through shaft 16 to communication with a irrigationconduit 49, which connects to irrigation nozzles 50. In this example,the conduit 49 is internal, connecting to the nozzles 50 in the centerof toe housing 40. Alternatively, one or more irrigation nozzles 50 maybe provided in stabilizing surfaces 22, and the conduit 49 maycommunicate externally in the manner of vacuum conduits 48.

[0160]FIG. 26 is a view of the underside of foot 17 in the embodimentshown in FIG. 25. FIG. 26 shows suction pads 52, 52′ mounted to theundersides of stabilizing surfaces 22, 22′. The pads include a matingperimeter 54 which engages the tissue surface of the beating heart,typically at the site of an anastomosis, and creates a bonding pressureto the tissue upon application of vacuum within pad 52, 52′.

[0161] As shown, various conformations of suction pads 52 are feasible.In this example, pad 52 includes subdividing webs 56 with divide the padsurface into a plurality of subpad areas or suckers 57. Aninterconnecting pad plenum 58 may be included to control pressure of onesucker relative to the adjacent, e.g., by metering holes which preventloss on suction by one sucker 57 in the event of leakage in the adjacentsucker. Alternative pad 52′ includes a grid 60 within the matingperimeter 54. The grid 60 controls tissue contact, and may provide aselected degree of friction with tissue.

[0162] In one preferred embodiment, pads 52, 52′ are configured asdisposable units, the pads 52, 52′ being mounted to disposable sleeves61, 61′ including disposable conduits 48, 48′. The sleeves 61, 61′ aremounted upon stabilizing surfaces 22, 22′ (e.g., slipped over and heldby friction) and connected to vacuum ports 62, 62′ in shaft end cap 38prior to surgery.

[0163] FIGS. 27A-27B illustrate how the toes 19 are able to pivot andlock in place. FIG. 27A is an detail plan view of one toe 19 togetherwith a portion of toe housing 40 and FIG. 27B is a longitudinal sectionview of the same subject. The toes 19 are pivotally joined to toehousing 40 by pivot pins 64, permitting rotation of the toes towards oraway from foot centerline 66 to cycle between the stowed, furled toeposition and the spread, deployed toe position as shown by Arrow B.

[0164] The toe spreading rotation is activated by tension on cable 21 asadjustably applied by the cable tensioner 23 and cable 20, previouslyshown in FIG. 23. Connector cable 21 (previously shown in FIG. 24) isfixed at cable distal end 65 to toe casing 68, as shown in FIG. 27B. Thecable distal end 65 may be fixed by any suitable means, such as byswaging, splayed in soldered socket, set screw or the like. Such fixingoccurs at a point outboard of pin 64 (farther from centerline 66).Tension on cable 21 thus tends to rotate toe casing 68 outwards in thedirection shown by Arrow B until stabilizing surfaces 22 are offset fromcenterline 66 by a selected offset h. Outward rotation of toe 19 islimited to a selected angle by mechanical stop, such as contact with toehousing 40 at area 67.

[0165] Following toe rotation, the action of cable 21 acts tofrictionally lock or adjustably brake toe 19 from further movement asfollows: Pivot pin 64 engages casing 68 with a selected degree oflongitudinal clearance or play as indicated by clearance spaces 69 and70, thus permitting casing 68 to move slightly longitudinally in thedirection shown by Arrow C as tension is applied to cable 21. Thismovement of casing 68 in turn pulls on stabilizer mounting ball 72 whichmounts stabilizing surface 22 by engagement of toe socket 74. Contact ofball 72 with socket 74 at distal contact area 75 in turn causes movementof ball 70 in the direction of Arrow D. Ball 72 in turn impinges uponthe distal end of push-rod 76 at contact area 77, moving push-rod 76along the toe axis in the direction shown by Arrow E. The push-rod 76 inturn contacts rod seating pin 78 at contact point 79, preventing furthermovement of rod 78. The clearances at spaces 69, 70, 75, 77 and 79 areselected so that when the cable 21 is tensioned to a selected lockingtension, the frictional forces at these contact areas is substantial andacts as a locking break to effectively resist and prevent rotationalmotion of ball 72 in ball housing 74 during the conduct of surgery.Optionally, surface 77 of pin 76 may be provided with an abrasivecoating or pattern to increase friction (e.g., bonded diamond dust).

[0166] Note that the tension of cable 20 is also passed via the forceson toe housing 40 to the one or more ball joints 36, 37, creating a lockor braking friction in these joints at the same time that thestabilizing surface joint 72, 74 is locked.

[0167] Preferably at a reduced or intermediate tension of cable 21, thefriction at contacts 75 and 77 is sufficient to partially resistrotation or adjustably brake ball 72, to permit stabilizer surface 22 toby “manually” rotated within socket 74 for controlled adjustment ofsurfaces 22 to target tissues, such as by action of robotic endeffectors operating within a body cavity. Optionally, the degrees offreedom and range of motion of ball and socket joint 72, 74 may beselectively enabled and limited by suitable slots and limit pins insocket 74 and ball 72.

[0168] FIGS. 28A-28B are section views of the external or base portionof the stabilizer 15 showing the quick-release mechanism 32 in the fixedand released positions respectively. Note in FIG. 28A that theadjustable cable tensioner 23 may be preadjusted to a selected tensionof cable 20, as described above, so that the knob 24 bears on thrustbearing 28. In this example, thrust bearing 28 is seated on bearingplate 80 in proximal shaft housing 30. The bearing plate 80 is in turnsupported by release plate 82. An opposed pair of release handles 84,84′ are mounted to the sides of housing 30 by rigid connections to axles85, 85′ which are in turn pivoted to the sides of housing 30. The axles85, 85′ are re rigidly connected to internal release cams 86, 86′ withinhousing 30. In the example shown, each of release cams 86 comprises around section eccentrically mounted to axle 85, so as to have anangularly-variable cam-like profile relative to the axle 85. The camprofile of the release cam 86 is configured to contact and supportrelease plate 82 when the handle 84 is moved to the closed position asshown by Arrow F in FIG. 28A, i.e., the surface portion of cam 86 incontact with plate 82 is at or near the maximum or high point of the camprofile when the levers are closed. The cam-supported release plate 82in turn rigidly supports bearing plate 80 to maintain cable tension.

[0169] As shown in FIG. 28B, when the handles 84′,84′ are moved to theopen position as shown by Arrow G, the release cams 86, 86′ are rotated,and the cam profile is configured to contact the plate 82 at or near alow point of the profile when the handles 84 are in the open position.Both the bearing plate 80 and the release plate 82 are axially movablymounted in housing 30, so that as the release plate tends to movedownward in response to cable tension, thus releasing the cable tensionwithout requiring any adjustment of knob 24. The cable may be returnedto the original tension by returning the handles 84′,84′ to the closedas shown by Arrow F in FIG. 28A. The mechanical advantage of cams 86relative to handles 84 may be selected to provide a predetermined motionof plate 82 as the handles are moved.

[0170] Optionally the cam 86 may be slightly over-center when the leversare closed to be stabilize the closed position. The handles 84 and/orcams 86 may also be spring biased or balanced to be stable closed orbi-stable in both open and closed positions and may be inter-geared tooperate symmetrically. Optionally, compression adjusters, such as springwashers and the like, may be placed between plates 80 and 82 to limit orcontrol the cable tension. Alternative levers with mechanical advantagemay be used in substitution for release cams 86.

[0171] In one embodiment, the cam profile is selected so that, when knob24 is adjusted to lock the motion of foot 17 as described above, therelease of tension when the handles 84 are then moved to the openposition (Arrow G), leaves a selected degree of residual cable tension,maintaining toe outward position (Arrow B as shown in FIGS. 27A-27B),and permitting controlled, partially-braked motion of surfaces 22 andjoints 36/37. Thus, in the released position, the surgeon or assistantmay conveniently adjust the surfaces 22 to mate with the target tissue,e.g., by the use of robotic surgical end effectors, and then re-lock thefoot 17 precisely and quickly by closing levers 84.

[0172]FIG. 29 is a detailed view of the stabilizer foot 17 as rotated tothe stowed or furled configuration to facilitate insertion orretraction. In surgical use, the stabilizer is typically insertedthrough a narrow cannula (not shown) passing through an incision in thepatient's body wall. The compact stowed configuration permits the footto fit in a narrow cannula. After loosening cable tension by action ofthe cable tensioner 23, the toes 19 may be rotated inward as shown byArrows B′. Each stabilizing surface 22 may be aligned with the axis ofshaft 16 by transversing motion of the ball-socket joint 72,74 alongslot 88 as shown by Arrow H. Finally, each of the stabilizing surfaces22 may be rotated about its own axis as shown by Arrows I to lieassembled facing one another, the assembled stabilizing surface profilepreferably approximating a rounded overall shape. Thus aligned, the footmay be inserted into and along the cannula until the foot 17 extendsinto the body cavity adjacent the surgical site.

[0173] Note that the contours of the toe housing 40, toes 19 andsurfaces 22 are preferably generally smooth and rounded, facilitatingautomatic alignment of these elements with the cannula opening as thefoot 17 is retracted. In addition, these foot elements may bemanipulated by the surgeon or assistant to assist retraction, e.g., byuse of the end effectors of a surgical robotic system.

[0174] Additional Embodiment #2

[0175]FIG. 30 illustrates a second additional embodiment of thestabilizer. FIG. 30 is a perspective view showing the distal end ofshaft 91 of the stabilizer 90. An attached foot portion 92 is comprisedof stabilizing surfaces 93, 93′ which are supported by toe portions 94,94′, respectively. The toe portions 94, 94′ are joined by a split ballmounting 96 which functions in a manner similar to the spherical splitball shell 1041, 1048 previously described. The split ball mounting 96allows the toe portions 94, 94′ to rotate from the furled or stowedconfiguration to an open or deployed configuration. The shaft 91 rigidlyconnects to a joint socket housing 98 which encloses and mounts splitball 96 at its distal end. FIG. 31 is a top view of the stabilizer 90distal end and FIG. 32 is a side view of the stabilizer 90 distal end.

[0176]FIG. 33 shows stabilizer 90 with the toe portions 94, 94′ and thestabilizing surfaces 93, 93′ rotated outwards by the split ball mounting96 to the deployed configuration. The split ball mounting 96 and toeportions 94, 94′ may be transversed along slot 99 to move thestabilizing surfaces 93, 93′ collectively to positions at an angle tothe shaft axis. Note the plurality of pocket-grooved cleats 95 onsurfaces 93 for holding flexible members such as Silastic tubing andsuture material.

[0177]FIG. 34 is a frontal elevation view of the stabilizing surfaces93, 93′ nested in an overlapping configuration within the overalldiameter of the joint housing 98. FIGS. 35A and 35B are side and planlongitudinal cross-sectional views of the split ball joint 96 of thestabilizer and socket housing 98. FIG. 35A is a section along Line35A-35A as shown in FIG. 34 (generally along slot 99), and FIG. 35B is asection along Line 35B-35B as shown in FIG. 34 (generally perpendicularto slot 99). Note that the split ball joint 96 comprises a right andleft generally hemispherical ball sides 101 and 101′, assembled movablytogether in contact along ball junction 106 to form collectively agenerally spherical body which is housed and movably contained betweeninner socket member 103 and outer socket member 104. Ball side 101mounts toe 94 and ball side 101′ mounts toe 94′. Inner socket member 103and outer socket member 104 are fixedly mounted to socket housing 98which is in turn mounted to shaft 91.

[0178] The respective ball sides 101, 101′ may be move in concert(without relative motion between ball halves) or may be movedindependently. The ball halves 101, 101′ may be rotated within thesocket 103/104 axially, i.e., along the axis of the respective toe 94.The ball halves 101, 101′ may also be moved transversely, i.e., to swinglaterally to follow slot 99 or alternatively to move perpendicular toslot 99 within the clearance of the slot width. Note that in FIG. 35B,the toes 94, 94′ have been traversed along slot 99 until the balljunction 106 lies generally perpendicular to the axis of shaft 91.

[0179] Pushrod 108 extends through the hollow center of shaft 91 and maybe driven (see FIGS. 36A-36B) in the direction of Arrow J tofrictionally impinge upon the adjacent ball halves at distal contactsurface 109, causing the ball joint 96 to be frictionally locked orbraked. Note that when the pushrod 108 contact is with only one ballhalf, as in FIG. 35B, friction is still induced by pressure at balljunction 106, and at contact with outer socket 104. Thus both balls 101,and 101′ are braked or locked.

[0180] FIGS. 36A-36B are longitudinal cross-sectional views of the pushrod compression mechanism of the stabilizer, showing the handle or base110 from the side and top respectively, corresponding to the sections ofLine 36A-36A and Line 36B-36B respectively as shown in FIG. 34. Base orhandle 110 is rigidly mounted to hollow shaft 91. The pushrod 108extends outward beyond handle 110 to fixedly mount to knob 112. Knob 112is in threaded engagement with handle 110, and thus as knob 112 isscrewed inward into handle 110, pushrod 108 is driven in the directionof Arrow J.

[0181] Additional Embodiment #3

[0182]FIG. 37 is a section plan view of an additional embodiment of afoot 130 of the stabilizer. As shown in this embodiment, the foot 130comprises an ankle 18 and toes 19. The ankle 18 comprises a series ofballs 36 and intermediate socket rings 37, of which only one is shown,connected with a housing 2000. Seals 2002 may be present between theballs 36 and socket rings 37 and between the ball 36 and housing 2000.The cable 20 enters the housing 2000 and connects with the toes 19 byconnector cables 21. The cable 20 and connector cables 21 are joinedwith a cable crimp 2002. A push rod 2004 is disposed within each toe 19and is engageable with a diamond dust ball link 2006. Each link 2006 isattached to a stabilizing surface or tissue engaging member 22. Inaddition, a vacuum or irrigation line 2008 is disposed within each toe19 as shown. The principles of function and construction are generallysimilar to the Additional Embodiment #1.

[0183] Additional Embodiment #4

[0184]FIG. 38A is a section plan view of an additional embodiment of afoot 135 of the stabilizer. As shown in this embodiment, the foot 135comprises an ankle 18 and toes 19. Each toe 19 is comprised of a tensiontube 2020 which holds a push rod 2022. Each push rod 2022 has acup-shaped end 2024. The cup-shaped end 2024 is mated with a ball link2026, which is typically diamond dust coated or polished, by way of aninstallation hole 2028 to form a ball-and-socket joint. The ball link2026 is connected to a stabilizing surface or tissue engaging member 22.Opposite the cup-shaped end 2024, each push rod 2022 is joined with theankle 18. Within the ankle 18, a cam 2030 actuates the push rods 2022.The cam 2030 floats about a float pin 2032, as illustrated in FIG. 38B.In addition, the ankle 18 comprises an over-center spring 2034 as shown.In this example, the toes 10 are lockable by pushrod-actuation, whereinshaft mounted pushrod assembly 2036 bears on cam 2030.

[0185] Additional Embodiment #5

[0186]FIGS. 39A is a section plan view and FIG. 39B is an elevation ofan alternative embodiment 140 of a stabilizer including aspects of theinvention. In this example the stabilizer comprises a ball-joint ankleportion and tension-cable/cam or gear-actuated lockable toe portions.Embodiment 120 is generally similar to embodiment 135 of FIG. 38A-38B,except that cam 2030 is activated by a pair of subcams 2042, which arein turn actuated by cable 2043 and cable 2044. The cable actuationprovides flexibility as neck portion 2046 is rotatably adjusted.

[0187] Additional Embodiment #6

[0188] As previously described, to prepare the coronary artery CA foranastomosis, the coronary artery CA is isolated from blood flow bycinching the coronary artery CA upstream and downstream of the desiredlocation for anastomosis. Thus, when the anastomosis is made, blood willnot flow out into the workspace. The coronary artery CA may be isolatedby any known or suitable method. In some embodiments of the presentinvention, the coronary artery CA is to be isolated with the use offlexible members 502 which are held by the tissue engaging member 22rather than by vessel occlusion fasteners or fastening clips 350. FIG.40 provides an embodiment of a tissue engaging member 22 having aflexible member 502 removably attached thereto. In this embodiment, twodiscs 2100 are mounted on the tissue engaging member 22. Each disc 2100has a knurled perimeter 2102 and rotates eccentrically about a pivot pin2104. The discs 2100 are spaced apart so that the flexible member 502 ispinched between the discs 2100 as the flexible member 502 is pulled inthe direction of the arrow. As the member 502 is pulled, each disc 2100rotates and impinges against a torsion spring 2106. This holds theflexible member 502 in place.

[0189]FIG. 40A shows an embodiment of a spring cleat 150 for holding aflexible member (e.g., silastic tubing) which operates on a “jam cleat”principle generally similar to the embodiment of FIG. 40. The springcleat 150 includes a pair of leaf spring members 2120, each springmember 2120 being mounted at a fixed end to a corresponding spaced-apartpair of mounting elements 2122 so that the spring members 2120 lieadjacent and generally parallel to a mounting surface, such as the uppersurface of a stabilizing member 22. The spring members 2120 maycomprise, for example, a flexible plastic composition and the mountingelement 2122 may include a rivet fixed to the stabilizer, so as topenetrate and clamp the leaf spring member 2120 at its fixed end.Alternatively, springs 2120 may be fixed to the mounting surface bybonding, ultrasonic welding, screws or other fixation means. The freeends of the spring members extend towards one another, and are arrangedso as to provide a spring-to-spring contact zone 2126 when not holding aflexible member. The contact zone 2126 may be offset from the centerline2124 passing between the pair of mounting elements 2122.

[0190] As a flexible member 502, such as silastic tube, is pulled in aninsertion direction (Arrow 2128 a) in the direction of the offset, thespring members are urged apart, thus opening the contact zone 2126 toreceive the flexible member 502, while maintaining a steady clampingpressure of the spring end on the member 502. The contact zone portion2126 may have texture elements, such as serrations or teeth, to increasefriction with the member 502. In the event that a tension force on themember 502 tends to pull the member 502 in the opposite direction frominsertion (Arrow 2128 b), the combination of friction and clamping forcetends to cause the contact zone to close tighter, causing a “jam cleat”effect to greatly increase the force resisting further extraction. Themember 502 may be removed by pulling in the insertion direction whilepulling upwards (away from mounting surface) to slide the flexiblemember 502 out of the contact zone 2126. Alternatively, the springmembers 2120 may be of a rigid composition, with conventional torsionsprings being included in mounting elements 2122.

[0191] Additional Embodiment #7

[0192] FIGS. 41A-41B illustrate an additional embodiment 155 of thestabilizer of the present invention. FIGS. 41A-41B illustrate how thetoes 19 of the stabilizer are able to lock in place by movement ofhandles 2200. FIG. 41A illustrates the handles 2200 in an open position.As shown, the cable 20 is disposed within the shaft and ankle 18 andconnects with the toes (not shown). The proximal end of the cable 20 isconnected to a maximum lock control 2202 by a threaded cable coupler2204. The handles 2200 are connected with the shaft 16 and cable 20 byeccentric rollers 2206. By moving the handles 2200 in the direction ofthe arrows in FIG. 41A, the cable 20 is tightened and the toes arelocked in place. FIG. 41B illustrates the handles 2200 in the positionwherein the toes are locked in place. By moving the handles 2200 in thedirection of the arrows in FIG. 41B, the cable 20 is released and thetoes are again free to move. This embodiment also includes a washervacuum input 2208, a thrust 2210 and one or more seals 2212.

[0193] Additional Embodiment #8

[0194]FIG. 42 is a section elevation view of an alternative embodimentof a stabilizer 160 including aspects of the invention, showing in thisexample an optional pneumatic cable tensioning mechanism. Within theshaft 16, a pneumatic cylinder 2300 is disposed. The pneumatic cylinder2300 is coupled to the cable 20 by a cable coupler 2302. The cable 20 istensioned by actuation of the pneumatic cylinder 2300.

[0195] Additional Embodiment #9

[0196] FIGS. 43A-43B are a top view and an end view of one embodiment165 of the positioning and clamping system for the stabilizer 1000 whenused in minimally invasive surgery, optionally robotic surgery.Embodiment 165 is an alternative to the system 170 previously describedin relation to FIGS. 6A-6B. Thesystem 165 comprises a linkage of aplurality of lockable-releasable joints which are rigidly fixed to theside rail of an operating table T or similar support. In thisembodiments, the system 170 comprises a two-sided, pneumaticallyactuated system 2400 mountable to the rails of the operating table T.The system 2400 includes conformable members comprising a plurality oftension-cable lockable ball joints 2402. The ball joints 2402 arecomprised of balls 37 and intermediate socket rings 37 assembled in themanner as previously described in relation to the ankle 18 andillustrated in FIG. 12A or FIG. 12B. In addition, the joints 2402function in generally the same way as described in relation to the ankle18 wherein an internal adjustable tension cable (not shown) is used toapply compressive force upon the sets of ball joints, locking them byinternal friction forces, and rendering the linkage rigid. The system2400 includes an optional pneumatic cable tensioner, as previouslydescribed in relation to FIG. 42, attached to the pneumatic cylinder2300 by a swing latch 2402. Other alternative cable tensioners,optionally be included in the system 2400.

[0197]FIG. 43C illustrates how the ball joints 2402 may be joined withthe stabilizer 1000 to hold the stabilizer 1000 in place within thechest cavity of the patient. As shown, the ball joints 2402 may beconnected with pneumatic clamps 2500. The clamps 2500 are used to clampthe shaft 16 of the stabilizer 1000 as shown. The clamped portion of theshaft 16 is separated from the chest wall by a flange 2502 and anydistance of the shaft 16.

[0198] It should be noted that although the stabilizer embodimentsdescribed above are exemplified as hand-actuated and table mountedsystems, the stabilizers of the invention include alternativeembodiments mounted to and positioned by robotic systems, such as aredescribed in U.S. patent application Ser. No. 09/436,524 filed Nov. 9,1999, now issued as U.S. Pat. No. ______ and also published ascorresponding PCT Application WO 00/30551, which are incorporated byreference herein.

[0199] For example, the stabilizer embodiments described above may bemounted to the surgical tool interface of such robotic system, and thestabilizer may be positioned and fixed within the body cavity bymovements of the robotic servomechanical manipulator. In the stabilizercable 20 may be tensioned by actuation of a robotically actuated cabletensioner, operated by hydraulic, pneumatic or electromechanical cableretracting devices of known types, which may be mounted to the robotictool interface.

[0200] In addition, robotically actuated stabilizers such as describedin WO 00/30551 may additionally include suction mechanisms of the typedescribed herein, the suction tube or lumen being housed within oradjacent the tool shaft and communicating to a suction source (thesuction source may be robotically or manually controlled). A flexibleportion of the suction lumen may be included adjacent to the roboticallyactuated wrist-like members, to accommodate wrist motion. Similiarly,irrigation mechanisms such as described above may be included in theserobotic stabilizer systems.

[0201] Thus, while the present invention has been described herein withreference to particular embodiments thereof, a latitude of modification,various changes and substitutions are intended in the foregoingdisclosure, and it will be appreciated that in some instances somefeatures of the invention will be employed without a corresponding useof other features without departing from the scope of the invention asset forth. Therefore, many modifications may be made to adapt aparticular situation or material to the teachings of the inventionwithout departing from the essential scope and spirit of the presentinvention. It is intended that the invention not be limited to theparticular embodiment disclosed as the best mode contemplated forcarrying out this invention, but that the invention will include allembodiments and equivalents falling within the scope of the appendedclaims.

What is claimed is:
 1. A tissue stabilizer for endoscopically stabilizing a target tissue within a patient's body, the tissue stabilizer comprising: a shaft sized to allow insertion through an endoscopic cannula; and a manipulable foot connected with the shaft, wherein the foot comprises a first toe portion and a second toe portion, the first and second toe portions being rotatably coupled with the shaft, each toe portion comprising at least one suction port to apply suction to the target tissue during stabilization, the first toe portion and second toe portion rotateable to a first arrangement wherein the foot is insertable through the endoscopic cannula.
 2. A tissue stabilizer as in claim 1, wherein the first and second toe portions are rotatably coupled to the shaft by a split ball joint assembly, the split ball joint assembly allowing the first and second toe portions to rotate with respect to the shaft and with respect to each other.
 3. A tissue stabilizer as in claim 2, wherein each toe portion comprises a ring mount.
 4. A tissue stabilizer as in claim 3, wherein the split ball joint assembly further comprises a top ball shell and a bottom ball shell which together encase the ring mounts of the first and second toe portions to form a spherical split ball shell.
 5. A tissue stabilizer as in claim 4, wherein the toe assembly further comprises a torsion spring to rotate the first toe portion and second toe portion to a second arrangement wherein the first toe portion and second toe portion are at least 8 mm apart.
 6. A tissue stabilizer as in claim 1, wherein the foot further comprises an adjustable ankle coupling the first toe portion and the second toe portion to the shaft.
 7. A tissue stabilizer as in claim 6, wherein the foot is moveable in six degrees of freedom relative to the shaft by adjusting the ankle.
 8. A tissue stabilizer as in claim 6, wherein the ankle comprises an adjustable neck comprising a series of interlocking balls and intermediate socket rings.
 9. A tissue stabilizer as in claim 8, wherein each ball is independently rotateable against an adjacent ring to allow the neck to be adjusted.
 10. A tissue stabilizer as in claim 6, wherein the first toe portion is rotateably joined with the second toe portion by a spherical split ball assembly, and wherein the ankle comprises a housing within which the spherical split ball assembly is disposed.
 11. A tissue stabilizer as in claim 10, wherein the spherical split ball assembly is rotateable within the housing to adjust the position of the foot in relation to the shaft.
 12. A tissue stabilizer as in claim 1, further comprising at least one suction tube connectable with the at least one suction port.
 13. A tissue stabilizer as in claim 12, wherein the shaft comprises a suction lumen and the suction tube is insertable through the suction lumen.
 14. A tissue stabilizer as in claim 13, wherein the suction tube comprises a suction tip which is connectable with the at least one suction port by insertion into a suction tube receptacle.
 15. A tissue stabilizer as in claim 1, further comprising an irrigator.
 16. A tissue stabilizer as in claim 15, wherein the shaft comprises an irrigation lumen and the irrigator is insertable through the irrigation lumen.
 17. A tissue stabilizer for endoscopically stabilizing a target tissue within a patient's body, the tissue stabilizer comprising: a shaft having a proximal end and a distal end, the shaft sized to allow insertion through an endoscopic cannula; an adjustable ankle connected with the distal end of the shaft; a manipulable foot connected with the ankle, wherein the foot comprises a first toe portion rotateably joined with a second toe portion, each toe portion comprising at least one suction port to apply suction to the target tissue during stabilization, the first toe portion and second toe portion rotateable to a first arrangement wherein the foot is insertable through the endoscopic cannula; and a tension cable passing through the shaft wherein applying tension to the cable locks the ankle in position.
 18. A tissue stabilizer as in claim 17, wherein the ankle comprises an adjustable neck comprising a series of interlocking balls and intermediate socket rings.
 19. A tissue stabilizer as in claim 18, wherein each ball is independently rotateable against an adjacent ring to allow the neck to be adjusted.
 20. A tissue stabilizer as in claim 18, wherein each ball and socket ring has a hollow core through which the tension cable extends.
 21. A tissue stabilizer as in claim 20, wherein the balls and socket rings are arranged so that applying tension to the cable wedges the balls and socket rings together to lock the ankle in position by friction.
 22. A tissue stabilizer as in claim 20, wherein the balls and socket rings are shaped so that applying tension to the cable causes at least one ball to apply a force to at least one socket ring at an angle of at least 60 degrees in relation to the cable.
 23. A tissue stabilizer as in claim 17, wherein the first toe portion is rotateably joined with the second toe portion by a spherical split ball shell, and wherein the ankle comprises a housing within which the spherical split ball shell is disposed.
 24. A tissue stabilizer as in claim 23, wherein the spherical split ball shell is rotateable within the housing to adjust the position of the foot in relation to the shaft.
 25. A tissue stabilizer as in claim 23, wherein by applying tension to the cable the spherical split ball shell is locked within the housing so that the position of the foot is fixed in relation to the shaft.
 26. A tissue stabilizer as in claim 25, wherein the tension cable comprises a locking ball disposed within the housing and wherein applying tension to the cable moves the housing so that the spherical split ball shell is locked within the housing.
 27. A tissue stabilizer as in claim 17, further comprising a handle connected with the proximal end of the shaft, wherein rotation of the handle applies tension to the tension cable.
 28. A tissue stabilizer as in claim 27, wherein the handle comprises ratchet pawls which lock the cable under tension.
 29. A tissue stabilizer as in claim 27, wherein the handle comprises a release button which unlocks the cable from tension.
 30. A system for endoscopically stabilizing a target tissue within a patient's body, the system comprising: an endoscopic cannula; and a tissue stabilizer comprising a shaft sized to allow insertion through the endoscopic cannula, and a manipulable foot connected with the shaft, wherein the foot comprises a first toe portion rotateably joined with a second toe portion, each toe portion comprising at least one suction port to apply suction to the target tissue during stabilization, the first toe portion and second toe portion rotateable to a first arrangement wherein the foot is insertable through the endoscopic cannula.
 31. A system as in claim 30, further comprising an adjustable ankle disposed between the foot and the shaft.
 32. A system as in claim 31, wherein the ankle comprises an adjustable neck comprising a series of interlocking balls and intermediate socket rings.
 33. A system as in claim 32, wherein each ball is independently rotateable against an adjacent ring to allow the neck to be adjusted.
 34. A system as in claim 30, wherein the first toe portion is rotateably joined with the second toe portion by a spherical split ball shell, and wherein the ankle comprises a housing within which the spherical split ball shell is disposed.
 35. A system as in claim 34, wherein the spherical split ball shell is rotateable within the housing to adjust the position of the foot in relation to the shaft.
 36. A system as in claim 30, further comprising at least one suction tube connectable with the at least one suction port.
 37. A system as in claim 36, wherein the shaft comprises a suction lumen and the suction tube is insertable through the suction lumen.
 38. A system as in claim 36, wherein the suction tube comprises a suction tip which is connectable with the at least one suction port by insertion into a suction tube receptacle.
 39. A system as in claim 30, further comprising an irrigator.
 40. A system as in claim 39, wherein the shaft comprises an irrigation lumen and the irrigator is insertable through the irrigation lumen.
 41. A system as in claim 39, wherein the irrigator comprises an adjustable dispenser terminating in a spout portion.
 42. A system as in claim 41, wherein the dispenser comprises a plurality of beads coupled in a chain-like fashion.
 43. A method of endoscopically stabilizing a target tissue within a patient's body, the method comprising: inserting a tissue stabilizer through an endoscopic cannula wherein the tissue stabilizer comprises a shaft having a proximal end and a distal end, and a manipulable foot connected with the shaft wherein the foot comprises at least two toe portions, each toe portion comprising at least one suction port; positioning the manipulable foot against the target tissue; and applying suction to the target tissue through the at least one suction port to stabilize the target tissue.
 44. The method as in claim 43, wherein the foot comprises a first toe portion rotateably joined with a second toe portion, said method further comprising rotating the first or second toe portions to a first arrangement wherein the foot is insertable through the endoscopic cannula.
 45. The method as in claim 43, wherein the tissue stabilizer further comprises an adjustable ankle disposed between the foot and the shaft, said method further comprising adjusting the ankle to adjust the position of the foot in relation to the shaft.
 46. The method as in claim 45, wherein the adjustable ankle comprises an adjustable neck comprising a series of interlocking balls and intermediate socket rings, said method further comprising rotating at least one ball against an adjacent ring.
 47. The method as in claim 45, wherein the first toe portion is rotateably joined with the second toe portion by a spherical split ball shell and wherein the ankle comprises a housing within which the spherical split ball shell is disposed, said method further comprising rotating the spherical split ball shell within the housing to adjust the position of the foot in relation to the shaft.
 48. The method as in claim 43, wherein the shaft has a suction lumen therethrough, said method further comprising inserting a suction tube through the suction lumen.
 49. The method as in claim 48, wherein the suction tube has a suction tip, said method further comprising connecting the suction tip with the at least one suction port.
 50. The method as in claim 43, wherein the shaft has an irrigation lumen therethrough, said method further comprising inserting an irrigator through the irrigation lumen.
 51. The method as in claim 50, wherein the irrigator comprises an adjustable dispenser terminating in a spout portion, said method further comprising adjusting the dispenser so that the spout portion is directed at the target tissue.
 52. The method as in claim 51, further comprising supplying a fluid to the irrigator so that the fluid exits the spout portion.
 53. A method of endoscopically stabilizing a target tissue within a patient's body, the method comprising: inserting a tissue stabilizer through an endoscopic cannula wherein the tissue stabilizer comprises a shaft having a proximal end and a distal end, an adjustable ankle connected with the distal end of the shaft, a manipulable foot connected with the shaft wherein the foot comprises at least two toe portions, each toe portion comprising at least one suction port, and a tension cable passing through the shaft wherein applying tension to the cable locks the ankle in position; positioning the manipulable foot against the target tissue; and applying suction to the target tissue through the at least one suction port to stabilize the target tissue.
 54. A method as in claim 53, further comprising applying tension to the cable.
 55. A method as in claim 54, wherein the ankle comprises an adjustable neck comprising a series of interlocking balls and intermediate socket rings, each ball and socket ring having a hollow core through which the tension cable extends, and wherein applying tension to the cable wedges the balls and socket rings together to lock the ankle in position by friction.
 56. A method as in claim 54, wherein the foot comprises a first toe portion rotateably joined with a second toe portion by a spherical split ball shell and wherein the ankle comprises a housing within which the spherical split ball shell is disposed, and wherein applying tension to the cable locks the spherical split ball shell within the housing so that the position of the foot is fixed in relation to the shaft.
 57. A method as in claim 56, wherein the tension cable comprises a locking ball disposed within the housing and wherein applying tension to the cable moves the housing so that the spherical split ball shell is locked within the housing.
 58. A method as in claim 54, wherein the tissue stabilizer further comprises a handle connected with the proximal end of the shaft, and wherein applying tension to the cable includes rotating the handle.
 59. A method as in claim 58, wherein the handle further comprises ratchet pawls, said method further comprising locking the cable under tension with the use of the ratchet pawls.
 60. A method as in claim 59, wherein the handle further comprises a release button, said method further comprising depressing the release button to unlock the cable from tension.
 61. A vessel occlusion device for controlling blood flow in a blood vessel, the device comprising: a plate-like body having a bore intersecting a radial slot; a flexible member having a free end and fixed end, wherein the fixed end is fixedly attached to the body and wherein the flexible member has a diameter sized so that the member is frictionally held in the radial slot upon insertion of the free end into the radial slot.
 62. A device as in claim 61, wherein the flexible member comprises silicone tubing.
 63. A device as in claim 61, wherein the plate-like body has a length of approximately 7.9 mm and a width of approximately 2.5 mm.
 64. A device as in claim 63, wherein the plate-like body has a depth of approximately 1.3 mm.
 65. A device as in claim 63, wherein the bore has a diameter of approximately 1.3 mm and a slot width of approximately 0.25 mm.
 66. A device as in claim 65, wherein the flexible member has an outer diameter of approximately 0.05 inches.
 67. A method of endoscopically preparing a blood vessel associated with a target tissue for a surgical procedure, said method comprising: endoscopically positioning a tissue stabilizer at a first location against the target tissue to stabilize the tissue; endoscopically positioning at least one vessel occlusion device around the blood vessel to restrict blood flow therethrough; removing the tissue stabilizer from the target tissue while the vessel occlusion device remains in place.
 68. A method as in claim 67, further comprising repositioning the tissue stabilizer to a second location against the target tissue while the vessel occlusion device remains in place.
 69. A method as in claim 67, wherein the tissue stabilizer comprises a shaft sized to allow insertion through an endoscopic cannula and a manipulable foot connected with the shaft, wherein the foot comprises a first toe portion rotateably joined with a second toe portion, the first toe portion and second toe portion rotateable to a first arrangement wherein the foot is insertable through the endoscopic cannula, and wherein endoscopically positioning the tissue stabilizer comprises positioning the foot against the target tissue.
 70. A method as in claim 67, wherein the vessel occlusion device comprises a plate-like body having a bore intersecting a radial slot and a flexible member having a free end and fixed end, wherein the fixed end is fixedly attached to the body, and wherein endoscopically positioning at least one vessel occlusion device comprises passing the free end of the flexible member around the blood vessel and into the radial slot so that the member is frictionally held.
 71. A method of controlling blood flow in a blood vessel, said method comprising: providing a vessel occlusion device comprising a plate-like body having a bore intersecting a radial slot, and a flexible member having a free end and fixed end, wherein the fixed end is fixedly attached to the body; passing the free end of the flexible member around the blood vessel and through the bore so that the blood vessel is encircled by the flexible member and the plate-like body; pulling the flexible member so that the blood flow is restricted in the blood vessel; and sliding the flexible member into the radial slot so that the member is frictionally held.
 72. A method as in claim 71, further comprising sliding the flexible member out of the radial slot to release the flexible member so that blood flow through the blood vessel in increased.
 73. A method as in claim 71, further comprising adjusting the position of the flexible member by sliding the flexible member out of the radial slot and re-sliding the flexible member into the radial slot.
 74. A method as in claim 71, further comprising: providing a tissue stabilizer for endoscopically stabilizing a target tissue within or upon which the blood vessel is disposed; and positioning the tissue stabilizer against the target tissue to stabilize the tissue.
 75. A tissue stabilizer for endoscopically stabilizing a target tissue within a patient's body, the tissue stabilizer comprising: a shaft sized to allow insertion through an endoscopic cannula; and a manipulable foot connected with the shaft, wherein the foot comprises a first toe portion and a second toe portion, the first and second toe portions being rotatably coupled with the shaft by a rotating joint assembly, the rotating joint assembly providing that at least one of the first and second toe portions are rotatable with respect to the shaft and providing that the first and second toe portions are rotatable with respect to each other, the first toe portion and second toe portion rotatable to at least a first toe arrangement wherein the foot is insertable through the endoscopic cannula.
 76. A tissue stabilizer as in claim 75, wherein each toe portion comprises at least one suction port configured so as to apply suction to the target tissue during stabilization.
 77. A tissue stabilizer as in claim 75, wherein the first toe arrangement is configured so that the first toe portion lies overlapping at least a portion of the second toe portion.
 78. A tissue stabilizer as in claim 77, wherein the rotating joint assembly comprises a first a pivotal joint and a second pivotal joint, the first and second pivotal joints being coupled to the first and second toe portions respectively.
 79. A tissue stabilizer as in claim 77, wherein the rotating joint assembly comprises a split ball joint assembly.
 80. A tissue stabilizer as in claim 79, wherein the split ball joint assembly further comprises a first split ball portion coupled to the first toe portion, and a second split ball portion coupled to the first toe portion, the first and second split ball portions being disposed adjacent one another so as to define at least a portion of a generally spherical ball assembly.
 81. A tissue stabilizer as in claim 80, wherein each toe portion comprises a ring mount.
 82. A tissue stabilizer as in claim 81, wherein the first split ball portion is disposed adjacent the ring mount of the first toe, and the second split ball portion is disposed adjacent the ring mount of the second toe, the first and second split ball portions together encase the ring mounts of the first and second toe portions.
 83. A tissue stabilizer as in claim 75, further comprising an adjustable ankle disposed between the foot and the shaft and coupling the foot to the shaft.
 84. A tissue stabilizer as in claim 75, further comprising an irrigator.
 85. A tissue stabilizer as in claim 75, further comprising at least one suction tube connectable with the at least one suction port.
 86. A tissue stabilizer as in claim 75, further comprising a tension cable passing through the shaft wherein applying tension to the cable locks the foot in position with respect to the shaft and locks the toe portions in position with respect to one another.
 87. A tissue stabilizer as in claim 75, further comprising at least one cleat device mounted to a portion of the foot, the cleat device being configured to releasable hold a flexible elongate member for vessel occlusion.
 88. A joint assembly for adjustably supporting a portion of an endoscopic surgical instrument, comprising: at least one ball member having a generally axially symmetrical convex external surface portion; at least one socket member having a generally axially symmetrical concave internal surface portion; and the ball member matin g with the socket member by contact of the convex surface portion with the concave surface portion.
 89. The joint assembly of claim 88, wherein the convex surface portion of the ball member has a curvature in the axial direction which is substantially greater than the curvature in the axial direction of the concave surface portion of the socket member, the contact between the convex portion and the concave portion defining a zone of contact spaced radially outward from the axis of the socket portion.
 90. The joint assembly of claim 89, wherein the convex surface portion of the ball member has a generally spherical contour, and the concave surface portion of the socket member having a generally conical contour.
 91. The joint assembly of claim 90, wherein each of the ball member and the socket member have a core lumen, the core lumen of the ball member being in communication with the core lumen of the socket member, the zone of contact being spaced substantially radially outward from the core lumen of the ball member.
 92. The joint assembly of claim 91, further comprising a compression mechanism configured to selectably urge the ball member against the socket member, so as to produce a selectable frictional engagement of the ball member with the socket member to provide resistance to rotation of the ball member with respect to the socket member.
 93. The joint assembly of claim 92, wherein the compression mechanism includes a flexible tension member passing through each of the core lumens, the tension element coupling at a first end to the ball member and at a second end to the socket member, the compression mechanism providing for selectably retracting the tension member so as to urge the ball member against the socket member.
 94. The joint assembly of claim 89, wherein the joint assembly comprises a plurality of interconnected joint members, each joint member including one of said at least one ball members and one of said at least one socket members, the plurality of joint members being arranged in chain like fashion by the engagement of ball members with adjacent socket members.
 95. A irrigator assembly for an for an endoscopic surgical instrument for supplying or removing fluids from a surgical site, comprising an adjustable dispenser member including a plurality of interlocking beads coupled in a chain-like fashion; the beads each having a core lumen communicating with the core lumen of each adjacent bead, so as to define a conduit for the passage of fluid.
 96. The irrigator assembly of claim 95, wherein at least one bead includes a socket portion and a ball portion; the ball portion engaging a corresponding socket portion of a first adjacent bead; and the socket portion engaging a ball portion of an second adjacent bead.
 97. The irrigator assembly of claim 96, wherein the engagement of each ball portion with each socket portion is configured to produce a substantial non-locking frictional interaction, so as to resist rotation of the at least one bead with respect to adjacent beads, to provide for the stable adjustment of the dispenser configuration.
 98. The irrigator assembly of claim 97, wherein the dispenser member terminates in a spout member in communication with the core lumens, the irrigator being connectable to a fluid supply for causing the flow of a fluid through the core lumens and the spout member to the surgical site.
 99. The irrigator assembly of claim 98, wherein the dispenser member terminates in a intake member in communication with the core lumens, the irrigator being connectable to a suction source for causing the flow of a fluid through the core lumens and the intake member away from the surgical site.
 100. A method of endoscopically stabilizing a target tissue within a patient's body, the method comprising: inserting a tissue stabilizer through an endoscopic cannula wherein the tissue stabilizer comprises a shaft having a proximal end and a distal end, and a manipulable foot connected with the shaft wherein the foot comprises at least two toe portions; and positioning the tissue stabilizer with the use of a robotically operated surgical instrument from within the patient's body.
 101. A method as in claim 100, wherein positioning the tissue stabilizer comprises positioning the manipulable foot against the target tissue.
 102. A method as in claim 101, wherein positioning the manipulable foot comprises grasping at least one of the toe portions with the robotically operated surgical instrument. 